Health Insurance Basics

Health care can be expensive and health issues can happen unexpectedly. Even if you are healthy now, an accident or new health condition can quickly change your health. Health insurance can help cover the costs of your health care. The Iowa Insurance Division has information about health insurance on their website.

Does my employer have to give me health insurance?

Federal Law

Under the Affordable Care Act (ACA), employers with at least 50 full-time employees must provide health insurance that meets minimum standards to full-time employees or risk paying a penalty to the federal government.  These employers are called “Applicable Large Employers.” The IRS has more information about what the law requires of these employers at their ACA Information Center.

Employers with under 50 employees do not have these same requirements, but they may choose to give their employees health insurance. Similarly, employers may offer health insurance to people who do not count as “full-time” employees.

Iowa Law

Under Iowa law, all employers must offer employees “access to health insurance.” Iowa Code section 505.21.  To satisfy this requirement, Iowa employers can either:

• Provide eligible employees a written referral to where the eligible employee can receive information about health care or health insurance; or
• Offer coverage or contribute to health insurance or a health benefit plan.

Iowa Administrative Rule 191.74.4(1).

Iowa Administrative Rule 191.74.3 defines “eligible employee” to include regular full- and part-time workers.    

Employers cannot discriminate against employees in offering health insurance. Under Iowa Code section 509.1(1)(a), employees eligible for insurance under an employer insurance policy must be all the employees or all of any class or classes of employees determined by their employment type.

What if I don’t have health insurance through my job or through a family member’s job?

If you recently lost coverage because, for example, you or a family member lost their job, visit our page on Continuation of Health Coverage (COBRA) to see if you may qualify for continued coverage.

Another option for health insurance outside of your work is through the Health Care Marketplace. You can find detailed information about the Marketplace on HealthCare.gov. The HealthCare.gov Marketplace has specific enrollment dates, so make sure to watch carefully for information from HealthCare.gov if you would like to enroll in Marketplace insurance. Sometimes you can enroll outside of the open enrollment period. Visit HealthCare.gov’s “Find out if you can get health coverage now” page for more information.

For more information on the Affordable Care Act tax deductions and credits, visit  the IRS’s Affordable Care Act Tax Provisions page.

My employer offers me health insurance, but I’d rather have it through the Marketplace. Can I do that?

If you have insurance through your job that meets certain standards, you won’t qualify for savings on a health insurance plan through the Marketplace.

Visit HealthCare.gov’s page “People with coverage through a job” for more information on how having insurance through your job affects Marketplace coverage.

What if my insurance company denies coverage for a service?

There are two types of appeal rights when an insurance company denies coverage.

An internal appeal is a request to the health plan to review their original decision. You have 180 days after the Explanation of Benefits (EOB) to file an internal appeal.  For further guidance on filing an appeal with your health plan, call the customer service number on your insurance card. 

The second type of appeal is an external review, or the opportunity for an independent review of the decision. The Iowa Insurance Division has a detailed page explaining external review and how to request it. You may be eligible for an external review after all internal appeals have been exhausted, and the denial is based on medical necessity, appropriateness, health care setting, level of care, or the effectiveness of the health care service of treatment. There may also be a right to external review if the claim was denied as “investigational or experimental.”  An external review must be filed with the Iowa Insurance Division within 4 months of the date of receipt of the final adverse claim determination notice. 

For more information, visit the Iowa Insurance Division’s “Consumer Connection: How to Appeal Denied Health Insurance Claims.”

I have insurance, but I received a bill from a provider beyond what my insurance covers. Can they do that?

Protections do exist against what’s called “surprise” or “balancing” billing for health care. The protections are limited to specific situations. The Iowa Insurance Division has detailed information at their page “No Surprises Act Consumer Information.” The U.S. Department of Labor provides additional information in this FAQ document.

Does Iowa have any programs to help with health insurance for children?

Yes! Some families will qualify for free health care for their child through Medicaid. Iowa also has a program to help working families get affordable health care for their children: Healthy and Well Kids in Iowa (Hawki). The Iowa Department of Health & Human Services has more information on Hawki on their website.