The national guide covers how medical plans are designed:

• Plan types: HMOs, PPOs and POS plans.
• Cost sharing: deductibles, coinsurance, copays and out-of-pocket maximums.
• Accounts: HSAs paired with high-deductible plans.
• The ACA: essential health benefits, metal levels, and dependents to age 26.

Iowa's state questions on medical plans focus on Iowa's mandated benefits (Iowa Code chapter 514C), external review (chapter 514J), the Hawki children's program, and Iowa's prompt-pay rules.

Federal rules the Iowa questions also use

• Essential health benefits: all Marketplace plans cover the 10 essential health benefit categories, including mental health and substance use services. Pediatric dental and vision are essential benefits; adult dental and vision are not.
• Cost-sharing reductions require a Silver plan. The premium tax credit is refundable and reconciled on IRS Form 8962.
• Preexisting conditions: a plan may not reject an applicant, charge more, or refuse to cover essential benefits because of a preexisting condition.
• Young adults can stay on a parent's plan until 26.
• Individual mandate: the federal penalty for being uninsured applied only through plan year 2018.
• No Surprises Act (effective January 1, 2022): it protects against surprise out-of-network bills for:
  • emergency care;
  • certain care at in-network facilities;
  • air ambulance services. Uninsured patients can get a good faith estimate.

Iowa mandated benefits (chapter 514C)

External review (chapter 514J)

• After a final adverse determination, the covered person may ask the commissioner for external review within four months.
• The independent review organization's decision binds the carrier. The covered person may still appeal to district court.

Hawki (Iowa's CHIP program)

• Hawki uses federal Title XXI (CHIP) money (Iowa Code 514I.1).
• Eligible children are under 19, Iowa residents, in families at or below 300% of the federal poverty level, and not eligible for Medicaid (Iowa Code 514I.8).
• Eligibility runs 12 months before review.

Prompt pay and clean claims

• A clean claim is properly completed and doesn't involve coordination of benefits, a preexisting condition investigation or subrogation (Iowa Code 507B.4A).
• Clean claims are paid or denied within 30 days. Late payments earn 10% a year starting on the 31st day (Iowa Code 507B.4(3)(p); 191 IAC 15.32).
• Exempt from the prompt-pay rule:
  • liability, workers' compensation, and auto or homeowners medical payments coverage;
  • disability income;
  • long-term care.

Individual market terms

• Iowa's individual market rules exclude these limited coverages from the definition of a health benefit plan (Iowa Code 513C.3):
  • accident-only, specified disease and hospital indemnity;
  • dental and vision;
  • Medicare supplement and long-term care;
  • disability income.
• An eligible individual is a resident who had qualifying coverage, or a qualifying event, within the preceding 30 days.

Credit disability

Credit disability policies may exclude:

• a preexisting condition, only if it was treated in the six months before coverage and causes a loss in the six months after;
• normal pregnancy;
• intentionally self-inflicted injuries.

No other exclusions are allowed (191 IAC 28.8).

Common exam traps

• Iowa newborn notice is 60 days, longer than the common 31.
• Mammograms: baseline at 35–39, every 2 years at 40–49, then annual from 50.
• External review must be requested within 4 months, and the decision binds the insurer.
• Hawki covers children under 19 up to 300% FPL.
• Late clean claims earn 10% interest from day 31.
• Group continuation and the individual policy provisions are covered in their own guides.