Iowa Admin. Code r. 191-85.2

Current through Register Vol. 47, No. 8, October 30, 2024

Rule 191-85.2 - Definitions

As used in this chapter:

"ACA " means, collectively, the Patient Protection and Affordable Care Act (Pub. L. 111-148) and Health Care and Education Reconciliation Act (Pub. L. 111-152).

"Applicant" means an individual or entity applying or intending to apply for a navigator license.

"Business entity" means a corporation, association, partnership, limited liability company, limited liability partnership or other legal entity.

"Commissioner " means the Iowa commissioner of insurance.

"Credit" means continuing education credit. One credit is 50 minutes of instruction or reading material in an acceptable topic.

"Division " means the Iowa insurance division.

"Health insurance " means insurance that is primarily for the diagnosis, cure, mitigation, treatment, or prevention of disease or amounts paid for the purpose of affecting any structure of the body, including transportation that is essential to obtaining medical care, but excluding:

1. Coverage only for accident or disability income insurance, or any combination thereof;

2. Coverage issued as a supplement to liability insurance;

3. Liability insurance, including general liability insurance and automobile liability insurance;

4. Workers' compensation or similar insurance;

5. Automobile medical payment insurance;

6. Credit-only insurance;

7. Coverage for on-site medical clinics;

8. Coverage only for limited-scope vision benefits;

9. Benefits for long-term care, nursing home care, home health care, community-based care, or any combination thereof;

10. Coverage for specified disease or critical illness;

11. Hospital indemnity or other fixed indemnity insurance;

12. Medicare supplement policies;

13. Medicare, Medicaid, or the Federal Employee Health Benefit Program, 5 U.S.C. §§ 8901 -8914, as it existed on January 1, 2013;

14. Coverage only for medical and surgical outpatient benefits;

15. Excess or stop-loss insurance; and

16. Other similar insurance coverage under which benefits for health insurance are secondary or incidental to other insurance benefits.

"Individual" means a private or natural person, as distinguished from a partnership, corporation or association.

"License " means the authorization by the commissioner for a person to act as a navigator in the state of Iowa.

"Market place " means any health benefit exchange authorized under the ACA and established or operating in this state, including any exchange established or operated by the U.S. Department of Health and Human Services.

"Navigator" means the individual or business entity that is granted the title, duties, and responsibilities under 45 CFR § 155.210 of a navigator by the granting or appointing authority. A navigator would engage in the activities and meet the standards described in 45 CFR § 155.210, including:

1. Maintaining expertise in eligibility, enrollment, and program specification;

2. Conducting public education activities to raise awareness about the marketplace;

3. Providing information and services in a fair, accurate, and impartial manner, including information that acknowledges other health programs such as Medicaid and the healthy and well kids in Iowa program;

4. Facilitating selection of a qualified health plan;

5. Providing referrals for consumers with questions, complaints, or grievances to any applicable office of health insurance consumer assistance or health insurance ombudsman established under Section 2793 of the Public Health Service Act, or other appropriate state agency or agencies;

6. Providing information in a culturally and linguistically appropriate manner, including to persons with limited English proficiency; and

7. Ensuring accessibility and usability of navigator tools and functions for persons with disabilities.

"Navigator renewal notice" means a written or electronic communication issued by the division to inform a navigator about license renewal.

"Negotiate" means the act of advising a purchaser or prospective purchaser of a particular contract of insurance concerning any of the substantive benefits, terms or conditions of the contract provided that the person engaged in that act either sells insurance or obtains insurance for purchasers. The definition of "negotiate" shall not include:

1. Impartially informing a purchaser or prospective purchaser about substantive benefits, terms or conditions of a contract while facilitating the enrollment in a qualified health plan by providing fair, impartial, and accurate information that assists a purchaser or prospective purchaser with submitting an eligibility application;

2. Clarifying the distinctions among qualified health plans; and

3. Helping qualified individuals make informed decisions during a health plan selection process.

"Person" means an individual or entity.

"Producer" means a person required to be licensed in this state to sell, solicit or negotiate insurance.

"Qualified health plan" means a health benefit plan that has in effect a certification that the plan meets the criteria for certification described in Section 1311(c) of the ACA.

"Sell" means to exchange a contract of insurance by any means, for money or its equivalent, on behalf of an insurer.

"Solicit" means attempting to sell insurance or asking or urging a person to apply for a particular kind of insurance from a particular company.

"U.S. Department of Health and Human Services" means the United States Department of Health and Human Services and any of its subsidiaries.

Iowa Admin. Code r. 191-85.2

ARC 0981C, IAB 8/21/2013, effective 9/25/2013