Availability of short-term health insurance in Iowa

Yes. As of 2023, seven insurers have been approved to sell short-term health insurance in Iowa, although not all of them currently market these policies.

The average monthly premium for a short-term health insurance plan sold in Iowa was $154.80 in 2022, according to data from IHC Specialty Benefits.

Along with the longer allowable term limits, Iowa’s new rules (finalized in February 2019 and effective as of January 2020) impose a variety of restrictions on short-term health insurance in Iowa:

• Benefit maximums must be at least $500,000 for each policy term (for perspective, it’s fairly rare to see short-term plans with benefit caps below this amount; Indiana enacted legislation in 2019 to require benefit caps of at least $2 million on short-term plans; ACA-compliant plans do not have benefit caps).
• A variety of services must be covered, including inpatient care, outpatient care, and prescription drugs (this is important, as it’s common for short-term insurance to not cover outpatient prescription drugs at all)
• Out-of-pocket costs must be capped at no more than $30,000. The limit is lower for plans with terms shorter than four months. And for plans that have separate out-of-pocket limits for medical care and prescription drugs, the total out-of-pocket limits cannot exceed $20,000 and $10,000, respectively.
• Pre-existing condition exclusion periods cannot exceed the length of the initial term, and if the plan is renewable, it must be guaranteed renewable (which means pre-existing conditions would be covered in the subsequent terms, but insurers are not required to make their plans renewable).
• Preventive care must be covered after 180 days, although it can be subject to the deductible and other cost-sharing (unlike ACA-compliant plans, which must cover certain preventive care in full, as soon as the plan is in effect).

As described below, the Iowa Insurance Division had initially proposed stricter standards, but those were not accepted by the rule committee. The rules that were adopted in early 2019 represent a compromise — they do still impose a variety of requirements that aren’t found in other states, but they’re more lenient than the rules the Insurance Division had initially proposed.

Iowa’s Insurance Commissioner, Doug Ommen and Iowa Governor Kim Reynolds expressed support for the Trump Administration’s 2018 regulations for short-term insurance, which only limit such plans to initial terms of less than one full year and a total duration of up to 36 months (as opposed to the Obama Administration rule that limited short-term plans to three months in 2017 and most of 2018; note that the Biden administration has proposed a rule change that would revert to much stricter limits on short-term policies).

State regulators clarified in September 2018 that short-term health insurance in Iowa would be allowed to follow the new federal rules in terms of how long they can last. Regulators had proposed extensive new coverage mandates as well, and although those were rejected by the rules committee, a less strict version of the new rules was ultimately adopted in early 2019. Since January 2020, all short-term health insurance sold in Iowa has been required to comply with the state’s new regulations.

As of late 2019, state regulators had authorized three insurers to sell 364-day short-term plans in the state: United States Fire Insurance Company, Golden Rule Insurance Company, and First Chicago Insurance Company. Iowa officials noted that the sale and marketing of those plans were at the carriers’ discretion, but it appeared that none of them were available for purchase as of late 2019 (all of the available plans at that point had term limits of 90 days).

By early 2020, the Iowa Insurance Division announced that a total of five insurers had been approved to offer short-term plans that are compliant with the state’s new rules, with terms of up to 364 days. In addition to the other three insurers that had already been approved, National Health Insurance and Companion Life had been approved to sell short-term plans in Iowa in 2020.

The Insurance Division noted at that point that they were working with “several” other insurers that wished to offer short-term plans in the state. And by 2022, the list of approved insurers (which can be found here) had grown to seven.

The Iowa Insurance Division noted that plans that weren’t yet compliant with the state’s new rules (and that were capped at three-month terms) were still available for purchase up until December 31, 2019, and could remain in force until their termination date, which could have been as late as the end of March 2020. But those plans can no longer be sold; short-term plans must comply with the state’s new rules in order to be sold.

As of 2023, the Iowa Insurance Division website notes that seven insurers are authorized to sell short-term health insurance in Iowa, although they may or may not be actively marketing coverage:

• United States Fire Insurance Company
• Freedom Life Insurance Company of America
• Golden Rule Insurance Company (UnitedHealthcare)
• Companion Life
• National Health Insurance (Allstate Health Solutions)
• The North River Insurance Company
• Independence American Insurance Company (no longer selling short-term health insurance)

Short-term health insurance in Iowa can be purchased by applicants who can meet the underwriting guidelines the insurers use. In general, this means being under 65 years old (some insurers put the age limit at 64 years) and in fairly good health.

Short-term health medical insurance plans typically include blanket exclusions for pre-existing conditions, so they are not adequate for residents of the Hawkeye State who need certain medical care and seeking a short-term policy that will cover those needs.

If you’re in need of health insurance coverage in Iowa, your first step should be to see whether you’re eligible for a special enrollment period that would allow you to enroll in an ACA-compliant major medical plan. There are a variety of qualifying life events that will trigger a special enrollment period and allow you to buy a plan through the health insurance exchange in Iowa.

And there’s also an annual open enrollment period, from November 1 to January 15, during which you can buy a plan through the Iowa exchange without needing to have a qualifying life event. The plans available in the marketplace are purchased on a month-to-month basis, so you can enroll in one (with a premium subsidy if you’re eligible) even if you’re only going to need it for a few months before another policy takes effect.

Sometimes a short-term health insurance plan might be the least costly and most realistic option for stop-gap help paying for healthcare:

• If you missed open enrollment for ACA-compliant coverage and do not have a qualifying event that would trigger a special enrollment period.
• If you are newly employed and have a waiting period until you can be covered by your new employer’s health insurance plan; short-term insurance may provide a much more affordable (but less comprehensive) stopgap than COBRA or an ACA-compliant plan.
• If you will soon be eligible for Medicare and don’t have access to any other coverage in the meantime.
• If you’re not eligible for Medicaid or a premium subsidy in the exchange, an ACA-compliant plan might be unaffordable.

Some examples of who are ineligible for premium subsidies:

• People who are ineligible to enroll in a marketplace plan due to lack of a lawful immigration status.
• People who earn too much money to qualify for subsidies, although the American Rescue Plan and Inflation Reduction Act ensure that coverage is affordable regardless of income, at least through 2025.

Although the Iowa Division of Insurance agreed to allow for longer short-term plans soon after the federal rules were announced, the department also proposed extensive coverage requirements, which were slated to take effect in September 2018, for short-term plans that last more than 90 days. The state’s Administrative Rules Review Committee did not approve the proposed rules, however, so they ultimately did not take effect.

The Division of Insurance confirmed in mid-October that they were working with stakeholders to draft new rules, which were implemented in early 2019. As described above, they’re more lenient than the initially proposed rules.

Commissioner Ommen had noted earlier in 2018 that the state was considering regulations to ensure that short-term plans provide comprehensive (“fulsome”) coverage and allow at least one guaranteed renewal. In September 2018, the Iowa Insurance Department published proposed regulations that would have required short-term plans in Iowa to comply with the following requirements, but only if they had terms in excess of 90 days:

• Plans would not have been allowed to have benefit caps of less than $1,000,000.
• The deductible could not have been more than $10,000 (the plan could have had a separate prescription drug deductible of up to $10,000)
• The coinsurance that the member pays could not have been more than 40 percent, and total coinsurance charges could not have exceeded $15,000 per year.
• Coverage for various services would have been required, including: hospitalization; mental health and substance use disorder treatment; ambulatory/outpatient care; preventive care (including but not limited to vaccines, mammograms, paps, and PSA tests); prescription drugs (including coverage for at least one drug in each US Pharmacopeia category and class); medically necessary durable medical equipment; all other state mandate benefits under Iowa Code Chapter 514C.
• The rules that were ultimately adopted in early 2019 are more lenient in nearly every category. But they are still more robust than many other states’ rules for short-term health plans. And they apply to all short-term health insurance plans in Iowa, including those with terms of under 90 days (as opposed to the initially proposed rules, which would have only applied to plans with terms longer than 90 days).Throughout 2019, the only available short-term health insurance in Iowa was capped at 90 days, as no insurers had started to offer plans that were compliant with the new rules. Those plans, with longer terms, became available for purchase in 2020 (as noted above, Iowa has approved policies from six insurers as of 2021).The Insurance Divisions proposed some consumer protections that would have applied to all short-term plans, including those with terms of up to 90 days

Under the terms of the proposed rules (which were not approved by the rules committee), post-claims underwriting would have been prohibited for short-term plans in Iowa. In other words, the insurer would not have been allowed to go back and look at the person’s medical records after they had a claim in order to find pre-existing conditions and rescind the coverage.

Instead, medical underwriting would have been limited to only the time period before the policy took effect. And rescission would only have been allowed if the insurer could show that the insured “knowingly and intentionally misrepresented material facts relating to the insured’s health.” (this is the same as the rescission rules that apply to ACA-compliant plans, but short-term plans are not regulated by the ACA).

For plans with terms of 90 days or less, coverage for pre-existing conditions would not have been required, but insurers would have been required to state this clearly on the policy.

State hinted that one guaranteed renewal might be required, but that was not part of the state’s initial proposed regulations

In Ommen’s letter to CMS earlier in 2018, he noted that Iowa might opt to make at least one guaranteed renewal mandatory for short-term plans, to prevent an enrollee from ending up uninsured if they develop a pre-existing condition while covered under a short-term plan. The termination of a short-term plan is not a qualifying event, so it would not allow a person to purchase a new, ACA-compliant plan (ie, a plan that covers pre-existing conditions and can’t reject an applicant based on medical history).

But although the Insurance Division proposed numerous other requirements for short-term plans that last more than 90 days, guaranteed renewability was not part of the proposed regulations. The regulations that were adopted in early 2019 do note that renewable plans must be guaranteed-renewable (ie, medical underwriting cannot be used to determine eligibility for the renewal), but insurers are not required to offer renewals.