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Summary of differences between federal and state regulations
Employee health plans are generally covered under the federal jurisdiction of the Employee Retirement Income Security Act (ERISA).
Federal ERISA plans generally do not have to comply with state laws. ERISA rules preempt or block state laws that relate to ERISA plans. State insurance laws, however, do apply. The following are some of the state’s requirements:
Generally, self-funded plans for private entities are not subject to regulation by this state.
If the policy ceases because of termination of employment, the person and the person's dependents may continue their insurance under the group policy and may subsequently apply for a converted policy without evidence of insurability.
If vision care is included, treatment provided by an optometrist licensed.
The plan must include a provision for services performed by chiropractors, if covered.
The plan must include a provision for services performed by registered nurses
(§509.3)
Children are covered from the moment of birth (if family is covered) insurer must be notified of the birth or adoption within 60 days. Adopted children are covered from the earlier of the following:
- Date of placement of the child,
- Date of entry of order granting custody, or
- Effective date of adoption.
(§514C.1)
Plans that provide payment or reimbursement for any service within the scope of practice of a licensed dentist must provide benefits for the service whether the service is performed by a licensed physician or a licensed dentist. (§514C.3)
If the plan provides for prescription drugs, it must not require participants to obtain prescription drugs from a mail order pharmacy. (§514C.5)
Plans cannot deny coverage solely based upon a participant being diagnosed as having a fibrocystic condition. (§514C.7)
Children cannot be denied coverage because they are born out of wedlock, not claimed as a dependent on the obligor's federal income tax return, or does not reside with the obligor or in the insurer's service area. (§514C.9)
Coverage for adopted children must follow the same terms and conditions as apply to a biological, dependent child. (§514C.10)
Plans must provide for treatment provided by a physician assistant or an advanced registered nurse practitioner. (§514C.11)
If a plan is terminated, it must continue to provide coverage to a participant with a terminal illness. (§514C.17)
The plan must provide for the cost of equipment, supplies, and self-management training and education for the treatment of all types of diabetes mellitus when prescribed by a physician. (§514C.18)
The plan must provide for the administration of general anesthesia and hospital or ambulatory surgical center charges related to the provision of dental care services for people such as children under five years old, and those with medical conditions that would create significant or undue medical risk if it were denied. (§514C.20)
The plan must cover treatment of a biologically based mental illness if at least 50 percent of the employer's working days during the preceding calendar year employed more than 50 full-time equivalent employees; or the plan is issued to a small employer and it covers benefits for the treatment of mental illness. (§514C.22)
The maximum age for currently covered children to remain covered is 25 years old as long as the child is a resident of Iowa and is unmarried. (§509.3)
Iowa also has laws governing small group health coverage. (§513B)
If the plan covers any vaccination or immunization, it must cover benefits for a vaccination for human papilloma virus. (§514C.23)
Plans that cover cancer treatment must not discriminate between coverage benefits for prescribed, orally administered anticancer medication used to kill or slow the growth of cancerous cells and intravenously administered or injected cancer medications that are covered, regardless of formulation or benefit category determination by the contract, policy, or plan. (§514C.24)
The plan must cover benefits for medically necessary prosthetic devices when prescribed by a physician. (§514C.25)
Plans providing for third-party payment or prepayment of health or medical expenses must cover routine patient care costs incurred for cancer treatment in an approved cancer clinical trial to the same extent that such policy or contract provides coverage for treating any other sickness, injury, disease, or condition covered under the policy or contract, if the insured has been referred for such cancer treatment by two physicians who specialize in oncology and the cancer treatment is given pursuant to an approved cancer clinical trial. (§514C.26)
Insurers are prohibited from the following:
- Discriminating against an individual or a member of the individual's family on the basis of genetic information or genetic testing.
- Considering a genetic propensity, susceptibility, or carrier status as a preexisting condition for the purpose of limiting or excluding benefits, establishing rates, or providing coverage.
- Using genetic information or genetic testing for underwriting health insurance.
- Releasing genetic information pertaining to an individual without prior written authorization of the individual. (§729.6)
To implement the requirements of the federal Affordable Care Act, the state implemented the following:
- Adopted a new Chapter 76 of the Iowa Administrative Code regarding external reviews.
Effective 1/1/18, group plans of employers with at least 50 full-time equivalent employees working at least 50 percent of the company’s working days must provide coverage benefits to covered individuals under 19 years of age for the diagnostic assessment of autism spectrum disorders and for the treatment of autism spectrum disorders, including applied behavior analysis.
State
Contact
Regulations
Iowa Code
§509.3 (registered nurses, maximum age)
§514C.1 (newborns)
§514C.3 (dentists)
§514C.5 (prescriptions not mail order)
§514C.7 (fibrocystic conditions)
§514C.9 (children)
§514C.10 (adopted children)
§514C.11 (physician assistant or an advanced registered nurse practitioner)
§514C.17 (terminal illness)
§514C.18 (diabetes)
§514C.20 (anesthesia for children-dental)
§514C.22 (biologically based mental illness)
§514C.24 (prosthetic devices)
§514C.31 (applied behavior analysis for treatment of autism spectrum disorder — coverage)
§513B (small group health coverage)
§729.6 (genetic testing)
To find statutes, see:
www.legis.iowa.gov/
For more information specific to health benefits for women, see the topic Women’s Health Rights.
Federal
Contact
Employee Benefits Security Administration (EBSA)
Regulations
29 CFR chapter XXV (Parts 2509 – 2590)