2009 Iowa Code
Title 13 - Commerce
Subtitle 1 - Insurance and Related Regulation
CHAPTER 514E - IOWA COMPREHENSIVE HEALTH INSURANCE ASSOCIATION
514E.1 - DEFINITIONS.

        514E.1  DEFINITIONS.
         As used in this chapter, unless the context otherwise requires:
         1.  "Association" means the Iowa comprehensive health
      insurance association established by section 514E.2.
         2.  "Association policy" means an individual or group policy
      issued by the association that provides the coverage as set forth in
      the benefit plans adopted by the association's board of directors and
      approved by the commissioner.
         3.  "Carrier" means an insurer providing accident and sickness
      insurance under chapter 509, 514 or 514A and includes a health
      maintenance organization established under chapter 514B if payments
      received by the health maintenance organization are considered
      premiums pursuant to section 514B.31 and are taxed under chapter 432.
      "Carrier" also includes a corporation which becomes a mutual
      insurer pursuant to section 514.23 and any other person as defined in
      section 4.1, subsection 20, who is or may become liable for the tax
      imposed by chapter 432.
         4.  "Church plan" means the same as defined in the federal
      Employee Retirement Income Security Act of 1974, 29 U.S.C. § 3(33).
         5.  "Commissioner" means the commissioner of insurance.
         6.  "Creditable coverage" means health benefits or coverage
      provided to an individual under any of the following:
         a.  A group health plan.
         b.  Health insurance coverage.
         c.  Part A or Part B Medicare pursuant to Tit. XVIII of the
      federal Social Security Act.
         d.  Medicaid pursuant to Tit. XIX of the federal Social
      Security Act, other than coverage consisting solely of benefits under
      section 1928 of that Act.
         e.  10 U.S.C. ch. 55.
         f.  A health or medical care program provided through the
      Indian health service or a tribal organization.
         g.  A state health benefits risk pool.
         h.  A health plan offered under 5 U.S.C. ch. 89.
         i.  A public health plan as defined under federal regulations.

         j.  A health benefit plan under section 5(e) of the federal
      Peace Corps Act, 22 U.S.C. § 2504(e).
         k.  An organized delivery system licensed by the director of
      public health.
         l.  The hawk-i program authorized by chapter 514I.
         7.  "Federally eligible individual" means an individual who
      satisfies the following:
         a.  For whom, as of the date on which the individual seeks
      coverage under this chapter, the aggregate of the periods of
      creditable coverage is eighteen or more months with no more than a
      sixty-three day lapse of coverage, and whose most recent prior
      creditable coverage was under a group health plan, governmental plan,
      or church plan, or health insurance coverage offered in connection
      with any such plan.
         b.  Who is not eligible for coverage under a group health
      plan, Part A or Part B of Tit. XVIII of the federal Social Security
      Act, or a state plan under Tit. XIX of that Act, or any successor
      program, and does not have other health insurance coverage.
         c.  With respect to whom the most recent coverage within the
      coverage period described in paragraph "a" was not terminated
      based on a nonpayment of premiums or fraud.
         d.  If the individual had been offered the option of
      continuation coverage under a COBRA continuation provision or under a
      similar state program, and elected such coverage.
         e.  Who, if the individual elected continuation coverage as
      provided in paragraph "d", has exhausted the continuation
      coverage under the provision or program.
         f.  Who has been confirmed eligible under the federal Trade
      Adjustment Act of 2002, Pub. L. No. 107-210, as a recipient under
      that Act, by the department of workforce development and the federal
      internal revenue service.
         8.  "Governmental plan" means as defined under section 3(32)
      of the federal Employee Retirement Income Security Act of 1974 and
      any federal governmental plan.
         9. a.  "Group health plan" means an employee welfare benefit
      plan as defined in section 3(1) of the federal Employee Retirement
      Income Security Act of 1974, to the extent that the plan provides
      medical care including items and services paid for as medical care to
      employees or their dependents as defined under the terms of the plan
      directly or through insurance, reimbursement, or otherwise.
         b.  For purposes of this subsection, "medical care" means
      amounts paid for any of the following:
         (1)  The diagnosis, cure, mitigation, treatment, or prevention of
      disease, or amounts paid for the purpose of affecting a structure or
      function of the body.
         (2)  Transportation primarily for and essential to medical care
      referred to in subparagraph (1).
         (3)  Insurance covering medical care referred to in subparagraph
      (1) or (2).
         c.  For purposes of this chapter, the following apply:
         (1)  A plan, fund, or program established or maintained by a
      partnership which, but for this subsection, would not be an employee
      welfare benefit plan, shall be treated as an employee welfare benefit
      plan which is a group health plan to the extent that the plan, fund,
      or program provides medical care, including items and services paid
      for as medical care for present or former partners in the partnership
      or to the dependents of such partners, as defined under the terms of
      the plan, fund, or program, either directly or through insurance,
      reimbursement, or otherwise.
         (2)  With respect to a group health plan, the term "employer"
      includes a partnership with respect to a partner.
         (3)  With respect to a group health plan, the term
      "participant" includes the following:
         (a)  With respect to a group health plan maintained by a
      partnership, an individual who is a partner in the partnership.
         (b)  With respect to a group health plan maintained by a
      self-employed individual under which one or more of the self-employed
      individual's employees are participants, the self-employed
      individual, if that individual is, or may become, eligible to receive
      benefits under the plan or the individual's dependents may be
      eligible to receive benefits under the plan.
         10.  "Health care services" means services, the coverage of
      which is authorized under chapter 509, chapter 514, chapter 514A, or
      chapter 514B as limited by benefit plans established by the
      association's board of directors, with the approval of the
      commissioner and includes services for the purposes of preventing,
      alleviating, curing, or healing human illness, injury or physical
      disability.
         11.  "Health insurance" means accident and sickness insurance
      authorized by chapter 509, 514, or 514A.
         12. a.  "Health insurance coverage" means health insurance
      coverage offered to individuals, including group conversion coverage.

         b.  "Health insurance coverage" does not include any of the
      following:
         (1)  Coverage for accident-only, or disability income insurance.
         (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 clinic care.
         (8)  Other similar insurance coverage, specified in federal
      regulations, under which benefits for medical care are secondary or
      incidental to other insurance coverage or benefits.
         c.  "Health insurance coverage" does not include benefits
      provided under a separate policy as follows:
         (1)  Limited-scope dental or vision benefits.
         (2)  Benefits for long-term care, nursing home care, home health
      care, or community-based care.
         (3)  Any other similar limited benefits as provided by rule of the
      commissioner.
         d.  "Health insurance coverage" does not include benefits
      offered as independent noncoordinated benefits as follows:
         (1)  Coverage only for a specified disease or illness.
         (2)  A hospital indemnity or other fixed indemnity insurance.
         e.  "Health insurance coverage" does not include Medicare
      supplemental health insurance as defined under section 1882(g)(1) of
      the federal Social Security Act, coverage supplemental to the
      coverage provided under 10 U.S.C. ch. 55 and similar supplemental
      coverage provided to coverage under group health insurance coverage.

         13.  "Insured" means an individual who is provided qualified
      comprehensive health insurance under an association policy, which
      policy may include dependents and other covered persons.
         14.  "Involuntary termination" includes but is not limited to
      termination of group conversion coverage or where benefits under a
      state or federal law providing for continuation of coverage upon
      termination of employment will cease or have ceased.
         15.  "Medicaid" means the federal-state assistance program
      established under Tit. XIX of the federal Social Security Act.
         16.  "Medicare" means the federal government health insurance
      program established under Tit. XVIII of the Social Security Act.
         17.  "Organized delivery system" means an organized delivery
      system as licensed by the director of the department of public
      health.
         18.  "Policy" means a contract, policy, or plan of health
      insurance.
         19.  "Policy year" means a consecutive twelve-month period
      during which a policy provides or obligates the carrier to provide
      health insurance.
         20.  "Preexisting condition exclusion", with respect to
      coverage, means a limitation or exclusion of benefits relating to a
      condition based on the fact that the condition was present before the
      date of enrollment for such coverage, whether or not any medical
      advice, diagnosis, care, or treatment was recommended or received
      before such date.  

         86 Acts, ch 1156, § 1; 89 Acts, ch 304, §1003; 97 Acts, ch 103, §
      42, 43; 98 Acts, ch 1100, § 70; 2000 Acts, ch 1058, §47; 2001 Acts,
      ch 69, §23; 2002 Acts, ch 1111, §16; 2003 Acts, ch 108, §131; 2004
      Acts, ch 1110, §40--43; 2004 Acts, ch 1158, §6--9; 2008 Acts, ch
      1123, § 25, 26; 2008 Acts, ch 1188, § 17; 2009 Acts, ch 118, §2, 5
         Referred to in § 514E.2
         Organized delivery systems authorized, see 93 Acts, ch 158, §3