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, the open enrollment and special enrollment timing, and the conditions under which an insurer may refuse to offer or renew coverage.

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). Generally 2 or 3 years on misrepresentation, depending on policy type.
• 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, optionally renewable, and cancelable — and sets the disclosure requirements for each.

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 grace period, incontestability, misstatement of age, notice of claim, proof of loss, payment of claims, legal actions, and beneficiary.

Claims (Iowa Code 509.19)

Iowa Code 509.19 sets the claims-handling framework for Iowa group health policies, including timeframes for acknowledgment, investigation, and payment.

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, diabetes self-management training, and related medically necessary services — including blood glucose monitors, test strips, insulin, oral hypoglycemic agents, and education provided by certified diabetes educators.

Mammography (Iowa Code 514C.14 for Individual; 514C.4 for Group)

Iowa requires both individual (Iowa Code 514C.14) and group (Iowa Code 514C.4) accident and health policies to provide coverage for screening mammography. Coverage includes routine screening at intervals recommended by the American Cancer Society or other recognized medical authority, 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 to the insurer within a defined period — typically 31 days — to continue coverage beyond the initial automatic-coverage window.

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 either on the date of placement for adoption or the date of adoption, as defined by the policy and the statute. Pre-existing conditions of an adopted child may not be excluded if family coverage is otherwise in force.

Complications of Pregnancy (Iowa Code 514C.12)

Iowa Code 514C.12 requires that Iowa health policies covering pregnancy must cover complications of pregnancy on the same basis as any other covered medical condition. 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. Iowa Code Chapter 514C contains the state-level framework that applies in contexts not governed by the ACA, including certain limited-benefit health plans and certain grandfathered policies.

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: