2024 Iowa Code
Title XIII - COMMERCE
Chapter 514B - HEALTH MAINTENANCE ORGANIZATIONS
Section 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, inpatienthospital and physician care, and outpatient medical services rendered within or outside of ahospital. 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 orhospitalization, as well as the furnishing to any person of all other services for the purposesof 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 medicalor surgical care and treatment provided by an optometrist licensed under chapter 154, ifperformed within the scope of the optometrist’s license, and the plan would pay for the careand treatment when the care and treatment were provided by a person engaged in the practiceof medicine or surgery as licensed under chapter 148. The plan shall provide that the planenrollees may reject the coverage for services which may be provided by an optometrist if thecoverage is rejected for all providers of similar vision care services as licensed under chapter148 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 expirationof the applicable collective bargaining contract, if any, whichever is the later. This paragraphdoes not apply to enrollees eligible for coverage under Tit. XVIII of the Social Security Act orany 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 ofnecessary diagnosis or treatment provided by a chiropractor licensed under chapter 151if the diagnosis or treatment is provided within the scope of the chiropractor’s licenseand 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 licensedprofessions in describing the human ailment or its diagnosis or its treatment, if it wereprovided by a person licensed under chapter 148. The plan shall also provide that theplan enrollees may reject the coverage for diagnosis or treatment of a human ailment by achiropractor if the coverage is rejected for all providers of diagnosis or treatment for similarhuman ailments licensed under chapter 148 or 151. A prepaid group plan of health careservices may limit or make optional the payment or reimbursement for lawful diagnostic ortreatment service by all licensees under chapters 148 and 151 on any rational basis whichis not solely related to the license under or the practices authorized by chapter 151 or isnot dependent upon a method of classification, categorization, or description based upondifferences in terminology used by different licensees in describing human ailments or theirdiagnosis or treatment. This paragraph applies to services provided under plans made afterJuly 1, 1986, and to existing group plans on their next anniversary or renewal date, or uponthe 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 theSocial 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 employerpurchaser, a provision for payment of covered services determined to be medically necessaryprovided by a certified registered nurse certified by a national certifying organization, whichorganization shall be identified by the Iowa board of nursing pursuant to rules adopted bythe board, if the services are within the practice of the profession of a registered nurse as thatpractice is defined in section 152.1, under terms and conditions agreed upon between the Sat Dec 23 00:44:35 2023 Iowa Code 2024, Section 514B.1 (20, 0)

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§514B.1, HEALTH MAINTENANCE ORGANIZATIONS 2 employer purchaser and the health maintenance organization, subject to utilization controls.This paragraph shall not require payment for nursing services provided by a certifiedregistered nurse practicing in a hospital, nursing facility, health care institution, a physician’soffice, or other noninstitutional setting if the certified registered nurse is an employee of thehospital, nursing facility, health care institution, physician, or other health care facility orhealth care provider. This paragraph applies to services provided under plans within thisstate made on or after July 1, 1989, and to existing group plans on their next anniversary orrenewal 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 anindividual contract or coverage designed only for issuance to enrollees eligible for coverageunder Tit. XVIII of the federal Social Security Act, or under coverage which is rated on acommunity 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. [C75, 77, 79, 81, §514B.1]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; 2010 Acts, ch 1061, §180; 2010 Acts, ch 1193, §71 Referred to in §10A.711, 508C.5, 510D.1, 514.4, 514.23 Sat Dec 23 00:44:35 2023 Iowa Code 2024, Section 514B.1 (20, 0)

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