§ 513b-10

513B.10 Availability of coverage. 1. a. A carrier that offers health insurance coverage in the small group market shall accept every small employer that applies for health insurance coverage and shall acceptfor enrollment under such coverage every eligible individual who applies for enrollmentduring the period in which the individual first becomes eligible to enroll under the terms ofthe health insurance coverage and shall not place any restriction which is inconsistent witheligibility rules established under this chapter. b. A carrier that offers health insurance coverage in the small group market through a network plan may do either of the following: (1) Limit employers that may apply for such coverage to those with eligible individuals who live, work, or reside in the service area for such network plan. (2) Deny such coverage to such employers within the service area of such plan if the carrier has demonstrated to the applicable state authority both of the following: (a) The carrier will not have the capacity to deliver services adequately to enrollees of any additional groups because of its obligations to existing group contract holders and enrollees.

following: (a) The carrier will not have the capacity to deliver services adequately to enrollees of any additional groups because of its obligations to existing group contract holders and enrollees. (b) The carrier is applying this subparagraph uniformly to all employers without regard to the claims experience of those employers and their employees and their dependents, orany health status-related factor relating to such employees or dependents. c. A carrier, upon denying health insurance coverage in any service area pursuant to paragraph 'b', subparagraph (2), shall not offer coverage in the small group market withinsuch service area for a period of one hundred eighty days after the date such coverage isdenied. d. A carrier may deny health insurance coverage in the small group market if the issuer has demonstrated to the commissioner both of the following: (1) The carrier does not have the financial reserves necessary to underwrite additional coverage. (2) The carrier is applying the provisions of this paragraph uniformly to all employers in the small group market in this state consistent with state law and without regard to the claimsexperience of those employers and the

ing the provisions of this paragraph uniformly to all employers in the small group market in this state consistent with state law and without regard to the claimsexperience of those employers and the employees and dependents of such employers, or anyhealth status-related factor relating to such employees and their dependents. e. A carrier, upon denying health insurance coverage pursuant to paragraph 'd', shall not offer coverage in connection with health insurance coverages in the small group marketin this state for a period of one hundred eighty days after the date such coverage is deniedor until the carrier has demonstrated to the commissioner that the carrier has sufficientfinancial reserves to underwrite additional coverage, whichever is later. The commissionermay provide for the application of this paragraph on a service area-specific basis. f. Paragraph 'a' shall not be construed to preclude a carrier from establishing employer contribution rules or group participation rules for the offering of health insurance coveragein the small group market. 2. A carrier, subject to subsection 1, shall issue health insurance coverage to an eligible small employer that applies for the

for the offering of health insurance coveragein the small group market. 2. A carrier, subject to subsection 1, shall issue health insurance coverage to an eligible small employer that applies for the coverage and agrees to make the required premiumpayments and satisfy the other reasonable provisions of the health insurance coverage notinconsistent with this chapter. A carrier is not required to issue health insurance coverageto a self-employed individual who is covered by, or is eligible for coverage under, healthinsurance coverage offered by an employer. 3. Health insurance coverage for small employers shall satisfy all of the following:a. A carrier offering group health insurance coverage, with respect to a participant or beneficiary, may impose a preexisting condition exclusion only as follows: (1) The exclusion relates to a condition, whether physical or mental, regardless of the cause of the condition, for which medical advice, diagnosis, care, or treatment wasrecommended or received within the six-month period ending on the enrollment date.However, genetic information shall not be treated as a condition under this subparagraph inthe absence of a diagnosis of the condition

ceived within the six-month period ending on the enrollment date.However, genetic information shall not be treated as a condition under this subparagraph inthe absence of a diagnosis of the condition related to such information. (2) The exclusion extends for a period of not more than twelve months, or eighteen months in the case of a late enrollee, after the enrollment date. Sat Dec 23 00:43:42 2023 Iowa Code 2024, Section 513B.10 (19, 0) §513B.10, SMALL GROUP HEALTH COVERAGE 2 (3) The period of any such preexisting condition exclusion is reduced by the aggregate of the periods of creditable coverage applicable to the participant or beneficiary as of theenrollment date. b. A carrier offering group health insurance 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 theadoption or placement for adoption, is covered under creditable coverage. This subparagraphshall not apply to coverage before the date of such adoption or placement for adoption.

ng on the date of theadoption or placement for adoption, is covered under creditable coverage. This subparagraphshall 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.c. A carrier shall waive any waiting period applicable to a preexisting condition exclusion or limitation period with respect to particular services under health insurance coverage for theperiod of time an individual was covered by creditable coverage, provided that the creditablecoverage was continuous to a date not more than sixty-three days prior to the effective date ofthe new coverage. Any period that an individual is in a waiting period for any coverage undergroup health insurance coverage, or is in an affiliation period, shall not be taken into accountin determining the period of continuous coverage. A health maintenance organization thatdoes not use preexisting condition limitations in any of its health insurance coverage mayimpose an affiliation period.

mining the period of continuous coverage. A health maintenance organization thatdoes not use preexisting condition limitations in any of its health insurance coverage mayimpose an affiliation period. For purposes of this section, 'affiliation period' means a periodof time not to exceed sixty days for new entrants and not to exceed ninety days for lateenrollees during which no premium shall be collected and coverage issued is not effective, solong as the affiliation period is applied uniformly, without regard to any health status-relatedfactors. This paragraph does not preclude application of a waiting period applicable to all newenrollees under the health insurance coverage, provided that any carrier-imposed waitingperiod is no longer than sixty days and is used in lieu of a preexisting condition exclusion. d. Health insurance coverage may exclude coverage for late enrollees for preexisting conditions for a period not to exceed eighteen months. e. (1) Requirements used by a carrier in determining whether to provide coverage to a small employer shall be applied uniformly among all small employers applying for coverageor receiving coverage from the carrier.

ents used by a carrier in determining whether to provide coverage to a small employer shall be applied uniformly among all small employers applying for coverageor receiving coverage from the carrier. (2) In applying minimum participation requirements with respect to a small employer, a carrier shall not consider employees or dependents who have other creditable coverage indetermining whether the applicable percentage of participation is met. (3) A carrier shall not increase any requirement for minimum employee participation or modify any requirement for minimum employer contribution applicable to a small employerat any time after the small employer has been accepted for coverage. f. (1) If a carrier offers coverage to a small employer, the carrier shall offer coverage to all eligible employees of the small employer and the employees’ dependents. A carrier shallnot offer coverage to only certain individuals or dependents in a small employer group or toonly part of the group. (2) Except as provided under paragraphs 'a' and 'd', a carrier shall not modify health insurance coverage with respect to a small employer or any eligible employee or dependentthrough riders, endorsements, or

t as provided under paragraphs 'a' and 'd', a carrier shall not modify health insurance coverage with respect to a small employer or any eligible employee or dependentthrough riders, endorsements, or other means, to restrict or exclude coverage or benefits forcertain diseases, medical conditions, or services otherwise covered by the health insurancecoverage. g. A carrier offering coverage through a network plan shall not be required to offer coverage or accept applications pursuant to subsection 1 with respect to a small employerwhere any of the following applies: (1) The small employer does not have eligible individuals who live, work, or reside in the service area for the network plan. (2) The small employer does have eligible individuals who live, work, or reside in the service area for the network plan, but the carrier, if required, has demonstrated to thecommissioner that it will not have the capacity to deliver services adequately to enrolleesof any additional groups because of its obligations to existing group contract holders and Sat Dec 23 00:43:42 2023 Iowa Code 2024, Section 513B.10 (19, 0) enrollees and that it is applying the requirements of this lettered paragraph

f its obligations to existing group contract holders and Sat Dec 23 00:43:42 2023 Iowa Code 2024, Section 513B.10 (19, 0) enrollees and that it is applying the requirements of this lettered paragraph uniformlyto all employers without regard to the claims experience of those employers and theiremployees and the employees’ dependents, or any health status-related factor relating tosuch employees and dependents. (3) A carrier, upon denying health insurance coverage in a service area pursuant to subparagraph (2), shall not offer coverage in the small employer market within such servicearea for a period of one hundred eighty days after the coverage is denied. 4. A carrier shall not be required to offer coverage to small employers pursuant to subsection 1 for any period of time where the commissioner determines that the acceptanceof the offers by small employers in accordance with subsection 1 would place the carrier ina financially impaired condition. 5. A carrier shall not be required to provide coverage to small employers pursuant to subsection 1 if the carrier elects not to offer new coverage to small employers in thisstate.

impaired condition. 5. A carrier shall not be required to provide coverage to small employers pursuant to subsection 1 if the carrier elects not to offer new coverage to small employers in thisstate. However, a carrier that elects not to offer new coverage to small employers underthis subsection shall be allowed to maintain its existing policies in the state, subject to therequirements of section 513B.5. 6. A carrier that elects not to offer new coverage to small employers pursuant to subsection 5 shall provide notice to the commissioner and is prohibited from writing new business in thesmall employer market in this state for a period of five years from the date of notice to thecommissioner. 92 Acts, ch 1167, §11; 93 Acts, ch 80, §7 – 9, 20; 97 Acts, ch 103, §24; 98 Acts, ch 1100, §69; 2001 Acts, ch 69, §16, 17, 39; 2017 Acts, ch 148, §45 Referred to in §513B.12 Sat Dec 23 00:43:42 2023 Iowa Code 2024, Section 513B.10 (19, 0)