514E.7 - POLICIES -- ELIGIBLE PERSONS -- DEPENDENT COVERAGE -- PREEXISTING CONDITIONS.

        514E.7  POLICIES -- ELIGIBLE PERSONS -- DEPENDENT      COVERAGE -- PREEXISTING CONDITIONS.         1. a.  An individual who is and continues to be a resident is      eligible for plan coverage if evidence is provided of any of the      following:         (1)  A notice of rejection or refusal to issue substantially      similar insurance for health reasons by one carrier or organized      delivery system.         (2)  A refusal by a carrier or organized delivery system to issue      insurance except at a rate exceeding the plan rate.         (3)  That the individual is a federally defined eligible      individual.         (4)  That the individual has a health condition that is      established by the association's board of directors, with the      approval of the commissioner, to be eligible for plan coverage.         (5)  That the individual has coverage under a basic or standard      health benefit plan under chapter 513C.         b.  A rejection or refusal by a carrier or organized delivery      system offering only stoploss, excess of loss, or reinsurance      coverage with respect to an applicant under subparagraphs (1) and (2)      is not sufficient evidence for purposes of this subsection.         c.  The association shall rescind coverage for an individual      who no longer resides in the state.         2. a.  An association policy shall provide that coverage of a      dependent unmarried person terminates when the person becomes      nineteen years of age or, if the person is enrolled full time in an      accredited educational institution, terminates at twenty-five years      of age.  The policy shall also provide in substance that attainment      of the limiting age does not operate to terminate coverage when the      person is and continues to be both of the following:         (1)  Incapable of self-sustaining employment by reason of mental      retardation or physical disability.         (2)  Primarily dependent for support and maintenance upon the      person in whose name the contract is issued.         b.  Proof of incapacity and dependency must be furnished to      the carrier within one hundred twenty days of the person's attainment      of the limiting age, and subsequently as may be required by the      carrier, but not more frequently than annually after the two-year      period following the person's attainment of the limiting age.         3.  An association policy that provides coverage for a family      member of the person in whose name the contract is issued shall also      provide, as to the family member's coverage, that the health      insurance benefits applicable for children include the coverage      required under section 514C.1.         4. a.  A preexisting condition exclusion shall not apply to a      federally defined eligible individual.         b.  Plan coverage shall not impose any preexisting condition      exclusion as follows:         (1)  In the case of a child who is adopted or placed for adoption      before attaining eighteen years of age and who, as of the last day of      the thirty-day period beginning on the date of the adoption or      placement for adoption, is covered under creditable coverage.  This      subparagraph shall not apply to coverage before the date of such      adoption or placement for adoption.         (2)  In the case of an individual who, as of the last day of the      thirty-day period beginning with the date of birth, is covered under      creditable coverage.         (3)  Relating to pregnancy as a preexisting condition.         (4)  In the case of an individual transferring to an association      policy from a basic or standard health benefit plan under chapter      513C beginning on or after January 1, 2005.         c.  Plan coverage shall exclude charges or expenses incurred      during the first six months following the effective date of coverage      for preexisting conditions.  Such preexisting condition exclusions      shall be waived to the extent that similar exclusions, if any, have      been satisfied under any prior health insurance coverage which was      involuntarily terminated, provided both of the following apply:         (1)  Application for association coverage is made no later than      sixty-three days following such involuntary termination and, in such      case, coverage under the plan is effective from the date on which      such prior coverage was terminated.         (2)  The applicant is not eligible for continuation rights that      would provide coverage substantially similar to plan coverage.         d.  This subsection does not prohibit preexisting conditions      coverage in an association policy that is more favorable to the      insured than that specified in this subsection.         e.  If the association policy contains a waiting period for      preexisting conditions, an insured may retain any existing coverage      the insured has under an insurance plan that has coverage equivalent      to the association policy for the duration of the waiting period      only.         5.  An individual is not eligible for coverage by the association      if any of the following apply:         a.  The individual is at the time of application eligible for      health care benefits under chapter 249A.         b.  The individual has terminated coverage by the association      within the past twelve months, except that this paragraph does not      apply to an applicant who is a federally eligible individual.         c.  The individual is an inmate of a public institution,      except that this paragraph does not apply to an applicant who is a      federally defined eligible individual.         d.  The individual premiums are paid for or reimbursed under      any government sponsored program or by any government agency or      health care provider, except as an otherwise qualifying full-time      employee, or dependent of the employee, of a government agency or      health care provider.         e.  The individual, on the effective date of the coverage      applied for, has not been rejected for, already has, or will have      coverage similar to an association policy as an insured or covered      dependent.  This paragraph does not apply to an applicant who is a      federally eligible individual.         f.  The individual is eligible for Medicare based upon age.         6.  The association is not required to make plan coverage      available to an individual who is covered or is eligible for any      continued group coverage under Internal Revenue Code § 4980B, the      federal Employee Retirement Income Security Act of 1974, codified at      29 U.S.C. § 1001 et seq., the federal Public Health Service Act of      July 1, 1944, codified at 42 U.S.C. § 201 et seq., or any continued      group coverage required by the state.  For purposes of this      subsection, an individual who would have been eligible for such      continuation of group coverage, but is not eligible solely because      the individual or other responsible party failed to make the required      election of coverage during the applicable time period, or terminated      such coverage prior to the end of such applicable time period, shall      be deemed to be eligible for such group coverage until the date on      which the individual's continuing group coverage would have expired      had an election been made or a termination not occurred.  
         Section History: Recent Form
         86 Acts, ch 1156, § 7; 90 Acts, ch 1163, §1--3; 96 Acts, ch 1129,      § 113; 97 Acts, ch 103, § 52, 53; 98 Acts, ch 1100, § 71; 2004 Acts,      ch 1110, §48, 49; 2004 Acts, ch 1158, §15--17; 2005 Acts, ch 70, §17,      51; 2006 Acts, ch 1117, §64; 2008 Acts, ch 1123, § 27