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) That the individual has a health condition that is established by the association‘s board 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.

Terms Used In Iowa Code 514E.7

  • Association: means the Iowa comprehensive health insurance association established by section 514E. See Iowa Code 514E.1
  • 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. See Iowa Code 514E.1
  • Board: means the engineering and land surveying examining board provided by this chapter. See Iowa Code 542B.2
  • Carrier: means an insurer providing accident and sickness insurance under chapter 509, 514, 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. See Iowa Code 514E.1
  • Child: includes child by adoption. See Iowa Code 4.1
  • Commissioner: means the commissioner of insurance. See Iowa Code 514E.1
  • Contract: means the same as defined in section 554D. See Iowa Code 554E.1
  • Contract: A legal written agreement that becomes binding when signed.
  • Creditable coverage: means health benefits or coverage provided to an individual under any of the following:
     a. See Iowa Code 514E.1
  • Dependent: A person dependent for support upon another.
  • Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
  • Federally eligible individual: means an individual who satisfies the following:
     a. See Iowa Code 514E.1
  • following: when used by way of reference to a chapter or other part of a statute mean the next preceding or next following chapter or other part. See Iowa Code 4.1
  • Health insurance: means accident and sickness insurance authorized by chapter 509, 514, or 514A. See Iowa Code 514E.1
  • Health insurance coverage: means health insurance coverage offered to individuals, including group conversion coverage. See Iowa Code 514E.1
  • Insured: means an individual who is provided qualified comprehensive health insurance under an association policy, which policy may include dependents and other covered persons. See Iowa Code 514E.1
  • Intellectual disability: means a diagnosis of intellectual disability or intellectual developmental disorder, global developmental delay, or unspecified intellectual disability or intellectual developmental disorder which diagnosis shall be made only when the onset of the person's condition was during the developmental period and based on an assessment of the person's intellectual functioning and level of adaptive skills. See Iowa Code 4.1
  • 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. See Iowa Code 514E.1
  • Medicare: means the federal government health insurance program established under Tit. See Iowa Code 514E.1
  • person: means individual, corporation, limited liability company, government or governmental subdivision or agency, business trust, estate, trust, partnership or association, or any other legal entity. See Iowa Code 4.1
  • Policy: means a contract, policy, or plan of health insurance. See Iowa Code 514E.1
  • state: when applied to the different parts of the United States, includes the District of Columbia and the territories, and the words "United States" may include the said district and territories. See Iowa Code 4.1
 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, that the health insurance benefits applicable for children include the coverage required under 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 adoption or placement for adoption, is covered under creditable coverage. This subparagraph 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 following the effective date of coverage for preexisting conditions. Such preexisting condition exclusions shall be waived to the extent that similar exclusions, if any, have been satisfied under any prior health insurance coverage which was involuntarily terminated, provided both 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.
 (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. If the association policy contains a waiting period for preexisting conditions, an insured 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. An individual is not eligible for coverage by the association if any of the following apply:

 a. The individual is at the time of application eligible for health care benefits under chapter 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.
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