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Title 5: Centrally Administered Programs Page 24 Iowa Department of Human Services Employees’ Manual Chapter E: Healthy and Well Kids in Iowa (hawk-i) Nonfinancial Eligibility Factors Revised July 3, 2009 Verification of Insurance Cancellation Individual Plans When the health insurance is through an individual (private) plan, accept the following verification: ♦ A signed statement from the insurance company or insurance agent, on company letterhead, that the coverage has ended or will be ending, or ♦ A policy termination notice, or ♦ A Certificate of Creditable Coverage (sometimes called a Letter of Coverage, Evidence of Coverage, or a Statement of Service) that verifies when coverage ended, or ♦ Verbal verification of ending coverage if there is a signed release from the applicant to contact the company or agent. The case record will be clearly documented with the date of the contact, the name of the person providing the information, their telephone number, and what was said. Employer Group Plans When the health insurance is coverage offered through an employer, accept the following: ♦ A signed statement from the employer that the coverage has ended or will be ending, or ♦ A signed statement from the insurance company or insurance agent, on company letterhead, that the coverage has ended or will be ending, or ♦ A Certificate of Creditable Coverage (sometimes called a Letter of Coverage, Evidence of Coverage, or a Statement of Service) that verifies when coverage ended, or ♦ Verbal verification of ending coverage if there is a signed release from the applicant to contact employer. The case record will be clearly documented with the date of the contact, the name of the person providing the information, their telephone number, and what was said. Always file copies of documents that have been provided as verification in the case file.