514C.13 Group managed care health plans — requirements attached to limited provider network plan offers. 1. As used in this section, unless the context otherwise requires:a. 'Carrier' means an entity that provides health benefit plans in this state. 'Carrier' includes an insurance company, group hospital or medical service corporation, healthmaintenance organization, multiple employer welfare arrangement, and any other personproviding health benefit plans in this state subject to regulation by the commissioner ofinsurance. b. 'Health benefit plan' means a policy, certificate, or contract providing hospital or medical coverage, benefits, or services rendered by a health care provider. 'Health benefitplan' does not include a group conversion plan, accident-only, specific-disease, short-termhospital or medical hospital confinement indemnity, credit, dental, vision, Medicaresupplement, long-term care, or disability income insurance, coverage issued as a supplementto liability insurance, workers’ compensation or similar insurance, or automobile medicalpayment insurance. c. 'Health care provider' means a hospital licensed pursuant to chapter 135B, a person licensed under chapter 148, workers’ compensation or similar insurance, or automobile medicalpayment insurance. c. 'Health care provider' means a hospital licensed pursuant to chapter 135B, a person licensed under chapter 148, 148C, 149, 151, or 154, or a person licensed as an advancedregistered nurse practitioner under chapter 152. d. 'Indemnity plan' means a hospital or medical expense-incurred policy, certificate, or contract, major medical expense insurance, or hospital or medical service plan contract. e. 'Large employer' means a person actively engaged in business who, during at least fifty percent of the employer’s working days during the preceding calendar year, employed morethan fifty full-time equivalent employees. f. 'Limited provider network plan' means a managed care health plan which limits access to or coverage for services to selected health care providers who are under contract with themanaged care health plan. g. 'Managed care health plan' means a health benefit plan that selects and contracts with health care providers; manages and coordinates health care delivery; monitors necessity,appropriateness, and quality of health care delivered by health care providers; and performsutilization ts with health care providers; manages and coordinates health care delivery; monitors necessity,appropriateness, and quality of health care delivered by health care providers; and performsutilization review and cost control. h. 'Point of service plan option' means a provision in a managed care health plan that permits insureds, enrollees, or subscribers access to health care from health care providerswho have not contracted with the managed care health plan. i. 'Small employer' means a person actively engaged in business who, during at least fifty percent of the employer’s working days during the preceding calendar year, employed at leastone and not more than fifty full-time equivalent employees. 2. A carrier which offers to a small employer a limited provider network plan to provide health care services or benefits to the small employer’s employees shall also offer to the smallemployer a point of service option to the limited provider network plan. 3. A carrier which offers to a large employer a limited provider network plan to provide health care services or benefits to the large employer’s employees shall also offer to the largeemployer one or more of the following: a. o a large employer a limited provider network plan to provide health care services or benefits to the large employer’s employees shall also offer to the largeemployer one or more of the following: a. A point of service plan option to the limited provider network plan. The price of the point of service plan option shall be actuarially determined. b. A managed care health plan that is not a limited provider network plan.c. An indemnity plan.4. A large employer that offers a limited provider network plan to its employees shall also offer to its employees one or more of the following: a. A point of service plan option to the limited provider network plan.b. A managed care health plan that is not a limited provider network plan.c. An indemnity plan.97 Acts, ch 88, §1; 2008 Acts, ch 1088, §131; 2011 Acts, ch 70, §27, 49; 2017 Acts, ch 148, §64 – 66 Referred to in §249A.37, 505.25, 514I.6 Sat Dec 23 00:45:06 2023 Iowa Code 2024, Section 514C.13 (28, 0)
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