Iowa

There are three sections of the state insurance law relevant to parity:

• Coverage for certain mental health conditions (514C.22 (pdf | Get Adobe® Reader®))
• Coverage for behavioral health conditions for military veterans (514C.27 (pdf | Get Adobe® Reader®))
• Coverage for autism services (514C.28 (pdf | Get Adobe® Reader®))

This section of the insurance law (514C.22) requires large employer fully-insured plans to cover services for certain conditions. Small employer fully-insured plans are not required to cover any mental health treatment, but if they do they must cover services for these certain conditions as well. The conditions are:

• Schizophrenia
• Bipolar disorders
• Major depressive disorders
• Schizo-affective disorders
• Obsessive compulsive disorders
• Pervasive developmental disorders
• Autistic disorders

The Commissioner of the Iowa Insurance Division is required to define these conditions by referencing the Diagnostic and Statistical Manual of Mental Disorders (DSM). Pervasive developmental disorders and autistic disorders are covered in much more detail by another section of the law (summarized below under “Autism”).

Plans cannot use annual maximums and lifetime maximums for mental health coverage if they are not in place for other medical coverage. If they do have annual and lifetime maximums in place for other medical coverage, the ones used for mental health services cannot be less than the ones for other medical coverage.

Plans must cover at least 30 days of inpatient care and 52 visits for outpatient care. Deductibles, copayments, and coinsurance must be the same for mental health services and other medical services.

Plans are specifically exempted from covering the following:

• “Marital, family, educational, developmental, or training services”
• “Care that is substantially custodial in nature”
• “Services and supplies that are not medically necessary or clinically appropriate”
• “Experimental treatments”

This section of the insurance law (514C.27) is identical to what is described above except that it requires plans to cover services for all mental health conditions and substance use disorders for veterans of the United States Armed Forces. Mental health conditions are defined as they are in the DSM, while substance use disorder is defined as “a pattern of pathological use of alcohol or a drug that causes impairment in social or occupational functioning, or that produces physiological dependency evidenced by physical tolerance or by physical symptoms when the alcohol or drug is withdrawn.”

This section of the insurance law (514C.28) requires state employee plans to cover autism services for children and young adults up through age 20.

Plans must cover an annual maximum of $36,000 that can be adjusted for inflation each year. Plans are not allowed to limit the number of outpatient visits unless the annual maximum is exceeded.

Deductibles, copayments, and coinsurance must be the same as those used for other medical services.

Insurance plans are allowed to review a child’s treatment plan once every six months, and the validity of a diagnosis of autism spectrum disorder can be reviewed once a year.

The following are listed as accepted treatments for autism:

• Pharmacy care
• Psychiatric care
• Psychological care
• Rehabilitative care (includes applied behavior analysis )
• Therapeutic care

Autism spectrum disorder is defined as autistic disorder, Asperger’s disorder, and pervasive developmental disorder not otherwise specified, but the Commissioner is allowed to define autism spectrum disorder as it is defined in the “most recent edition” of the DSM.