The national guide covers Medicare (Parts A, B, C and D), Medigap plan letters, Medicaid and the basics of long-term care. Iowa regulates Medicare supplement sales under 191 IAC chapter 37 and long-term care under Iowa Code chapter 514G and 191 IAC chapter 39. These notes cover the Iowa rules.

National concepts in brief

• Medicare is available at 65, or earlier for disability.
  • Part A: hospital insurance.
  • Part B: medical insurance.
  • Part C: Medicare Advantage.
  • Part D: prescription drugs.
• Medigap fills gaps in Original Medicare. The six-month open enrollment period starts with the first month a person is both 65 and enrolled in Part B.
• Long-term care pays for custodial care when a person can't perform activities of daily living or is cognitively impaired.

Medicare supplement rules (191 IAC chapter 37)

• Purpose: standardize and simplify Medigap coverage so buyers can compare plans (191 IAC 37.1).
• Open enrollment: no denial for health reasons during the six months starting with the first month the person is 65 and in Part B (191 IAC 37.21).
• Preexisting conditions (191 IAC 37.21):
  • A condition treated or diagnosed within six months before coverage may be excluded for the first six months.
  • No exclusion is allowed if the applicant has six months of creditable coverage.
  • Waivers that exclude named conditions are not allowed (191 IAC 37.5).
• Renewability: each plan is guaranteed renewable. It can't be cancelled or nonrenewed because of health (191 IAC 37.8).
• No duplication: selling duplicate Medicare supplement coverage is prohibited (Iowa Code 507B.9; 191 IAC 37.5, 37.31). Benefits may not duplicate Medicare.
• Medicare Advantage: a Medigap policy may not be issued to a Part C enrollee unless it takes effect after Part C ends (191 IAC 37.31).
• Prescription drugs: no Medigap policy with outpatient drug benefits has been issued since December 31, 2005 (191 IAC 37.5(5)).
• Benefits may not be limited to "usual and customary" charges.
• Free look: 30 days from delivery (191 IAC 37.28). Buyers also get the "Choosing a Medigap Policy" guide.
• Application: it must list policies sold to the applicant that are still in force, and those sold in the past five years that are no longer in force (191 IAC 37.27).
• Replacement:
  • The replacement notice is signed before the policy is issued or delivered.
  • The new insurer must waive preexisting, waiting and probationary periods to the extent already served under the old policy (191 IAC 37.33).
• Marketing (191 IAC 37.30):
  • Buyers must be told the policy may not cover all medical expenses.
  • Buyers get the contact information for the Senior Health Insurance Information Program (SHIIP), part of the Insurance Division.
  • Cold-lead advertising (failing to say that it solicits insurance and that a producer will make contact) is prohibited.
  • The terms "Medicare supplement" or "Medigap" may be used only for compliant policies.

Long-term care (chapter 514G and 191 IAC chapter 39)

Renewability: individual policies must be guaranteed renewable or noncancellable (191 IAC 39.6). "Level premium" may be used only if the insurer can't change the premium.

Benefits and exclusions:

• Prior institutional care: a policy that requires it may not require a stay of more than 30 days (Iowa Code 514G).
• Exclusions: mental and nervous conditions may be excluded, but Alzheimer's disease and irreversible dementia may not (191 IAC 39.6(2)).
• Preexisting conditions are defined by treatment within the six months before coverage (Iowa Code 514G).

Contestability (191 IAC 39.24):

• In the first six months, the policy can be rescinded for a material misrepresentation.
• After two years, it can be contested only for knowing and intentional misrepresentation of health facts.
• LTC policies may not be field-issued based on health status.

Protection against unintended lapse (191 IAC 39.22):

• The applicant designates another person to receive lapse notices, or signs a waiver. The insured is reminded of the right to change the designation at least every two years.
• Lapse notice goes out at least 30 days before lapse, and no sooner than 30 days after the premium is due.
• Reinstatement is available if, within five months, the insured shows cognitive impairment or loss of functional capacity.

Sales:

• An outline of coverage is given at the first solicitation (Iowa Code 514G).
• Free look: 30 days. Refunds are paid within 30 days of the return.

Partnership: Iowa has an LTC Partnership program. Partnership policyholders get a Medicaid asset disregard, which also applies to partnership policies from reciprocating states (191 IAC 39.78; Iowa Code 514H).

Producer training: a one-time 8-credit LTC course, then 4 credits every CE term (191 IAC 39.15). The one-time course is classroom training unless a self-study or online version is approved.

Other Iowa programs

• HIPIOWA is a nonprofit association whose members include all carriers providing health insurance in Iowa (Iowa Code 514E.2).
• Hawki covers children under 19 in families up to 300% of the federal poverty level (Iowa Code 514I.8).
• Misleading senior designations are prohibited (191 IAC 10.19(4)).

Common exam traps

• Medigap and LTC free looks are 30 days. Ordinary individual life and health free looks are 10 days.
• Six months of creditable coverage wipes out the Medigap preexisting exclusion.
• LTC can't exclude Alzheimer's, and can't require more than a 30-day prior institutional stay.
• LTC training is 8 credits up front, then 4 per term.
• The reinstatement window for cognitive impairment is five months.