Iowa Individual and Group Health Insurance

Iowa Individual Health Insurance

Eligibility (Iowa Code 513C.3(7) and (10))

Iowa Code 513C governs Iowa’s individual health insurance market. Iowa Code 513C.3(7) and (10) set eligibility rules — defining who qualifies as an eligible individual and what counts as an individual health benefit plan. The conditions under which an insurer may refuse to renew coverage are in Iowa Code 513C.6.

Required Provisions (Iowa Code 514A.3)

Iowa Code 514A.3 lists the required provisions every individual accident and health insurance policy issued in Iowa must contain. The outline tests these directly:

• Entire contract. The policy, application, and any attached endorsements constitute the entire contract.
• Time limit on certain defenses (incontestability). Two years on misrepresentation, in both forms of the provision Iowa allows.
• Grace period. A defined period during which premium may be paid late without lapse — typically 7, 10, or 31 days depending on payment mode.
• Reinstatement. Procedures for restoring a lapsed policy.
• Notice of claim. Insured must give notice of a claim within a defined period after a covered loss.
• Claim forms. Insurer must furnish claim forms to the insured within a defined period after notice.
• Proof of loss. Insured must furnish proof of loss within a defined period.
• Time of payment of claims. Claims must be paid promptly after the insurer receives proof of loss.
• Payment of claims. Identifies who is entitled to receive payment.
• Physical examination and autopsy. Insurer’s right during pendency of claim.
• Legal actions. Limitations on when and how legal action may be brought.
• Change of beneficiary. Procedural rules.

Renewability (Iowa Admin Rule 191-36.10)

Iowa Admin Rule 191-36.10 defines the categories of renewability for Iowa individual health insurance policies — noncancelable, guaranteed renewable, conditionally renewable, and optionally renewable — and Iowa Admin Rule 191-36.7 requires each policy to state its renewal, continuation, or nonrenewal provision on the first page.

Iowa Group Health Insurance

Eligibility (Iowa Code 509.1; 513B.2(10))

Iowa Code 509.1 defines eligible groups for group health insurance (parallel to the group life definition). Iowa Code 513B.2(10) provides additional definitions for the small employer group market.

Required Provisions (Iowa Code 509.3)

Iowa Code 509.3 lists the required provisions for Iowa group accident and health insurance policies, including the application attached or furnished with statements treated as representations rather than warranties, individual certificates for insured persons, the addition of newly eligible persons, and continuation of coverage after termination of employment or membership.

Claims (Iowa Code 509.19)

Iowa Code 509.19 requires an issuer of group health coverage to a group of 51 or more eligible employees to give the policyholder, on request once a year, the total claims paid and the total premiums by line of coverage.

Iowa Mandated Coverages

Iowa requires fully insured health plans to include several specific benefits. These mandates do not apply to self-funded employer plans, which are governed by ERISA and preempted from state insurance regulation.

Diabetes (Iowa Code 514C.18)

Iowa Code 514C.18 requires both individual and group health policies to provide coverage for diabetes equipment and supplies and diabetes self-management training and education, when prescribed by a physician or physician assistant.

Mammography (Iowa Code 514C.4)

Iowa Code 514C.4 requires both individual and group accident and health policies to provide coverage for screening mammography. Coverage includes at least a baseline mammogram at ages 35 through 39, one every two years at ages 40 through 49, and one every year from age 50, or more often if the woman’s physician recommends it, and diagnostic mammography when medically indicated.

Coverage for Newborns (Iowa Code 514C.1)

Iowa Code 514C.1 requires every Iowa health policy that provides family coverage to cover newborn children from the moment of birth, including coverage of congenital defects, premature birth, and care for serious medical conditions present at birth. The policy may require notification of the birth, and payment of any required premium, within 60 days after the date of birth.

Adopted Children (Iowa Code 514C.1 and 514C.10)

Iowa Code 514C.1 and 514C.10 require Iowa health policies that provide family coverage to cover adopted children on the same terms as biological children, beginning on the earliest of the date of placement for adoption, the date of an order granting custody for adoption, or the date of adoption. Pre-existing conditions of an adopted child may not be excluded if family coverage is otherwise in force.

Complications of Pregnancy (Iowa Admin Rule 191-15.11)

Iowa Admin Rule 191-15.11 bars Iowa health policies from treating complications of pregnancy differently from any other illness or sickness under the contract. Complications include serious conditions arising from pregnancy that require medical care beyond routine prenatal and delivery services.

Preexisting Conditions (Iowa Code Chapter 514C)

Iowa’s preexisting condition rules — once a major source of consumer concern — have been largely overtaken by the federal Affordable Care Act, which prohibits preexisting condition exclusions in non-grandfathered health plans. At the state level, Iowa Code 513C.7(2) bars an individual basic or standard health benefit plan from excluding losses incurred more than 12 months after coverage begins because of a preexisting condition, and Iowa Code Chapter 514C bars preexisting condition exclusions for newborn and adopted children.

Iowa Autism Spectrum Disorder Mandate (Iowa Code 514C.22, 514C.28, 514C.31, as amended by HF 330)

Iowa significantly expanded its autism spectrum disorder (ASD) insurance mandate in 2025. House File 330, signed by the Governor on June 11, 2025, applies to insurance policies delivered, issued for delivery, continued, or renewed on or after January 1, 2026 — the same effective date as the new Iowa exam outline. The amendments fundamentally change what Iowa group health plans must cover: