Iowa CHIP SPA #14 Final Version

Model Application Template for the State Children‟s Health Insurance Program

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Approval Date: 2 MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN‟S HEALTH INSURANCE PROGRAM

Preamble

Section 4901 of the Balanced Budget Act of 1997 (BBA) amended the Social Security Act (the Act) by adding a new title XXI, the State Children‟s Health Insurance Program (SCHIP). Title XXI provides funds to states to enable them to initiate and expand the provision of child health assistance to uninsured, low-income children in an effective and efficient manner. To be eligible for funds under this program, states must submit a state plan, which must be approved by the Secretary. A state may choose to amend its approved state plan in whole or in part at any time through the submittal of a plan amendment.

This model application template outlines the information that must be included in the state child health plan, and any subsequent amendments. It has been designed to reflect the requirements as they exist in current regulations, found at 42 CFR part 457. These requirements are necessary for state plans and amendments under Title XXI.

The Department of Health and Human Services will continue to work collaboratively with states and other interested parties to provide specific guidance in key areas like applicant and enrollee protections, collection of baseline data, and methods for preventing substitution of Federal funds for existing state and private funds. As such guidance becomes available, we will work to distribute it in a timely fashion to provide assistance as states submit their state plans and amendments.

Model Application Template for the State Children‟s Health Insurance Program

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Approval Date: 3 MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM ............................................................................................................................ 4 Section 1. General Description and Purpose of the State Child Health Plans and State Child Health Plan Requirements (Section 2101) ................................................................ 5 Section 2. General Background and Description of State Approach to Child Health Coverage and Coordination (Section 2102 (a)(1)-(3)) and (Section 2105)(c)(7)(A)-(B)) .. 10 Section 3. Methods of Delivery and Utilization Controls (Section 2102)(a)(4)) ........... 18 Section 4. Eligibility Standards and Methodology. (Section 2102(b)) ......................... 20 Section 5. Outreach (Section 2102(c)) ......................................................................... 30 Section 6. Coverage Requirements for Children‟s Health Insurance (Section 2103) .. 34 Section 7. Quality and Appropriateness of Care ............................................................. 40 Section 8. Cost Sharing and Payment (Section 2103(e)) ............................................ 44 Section 9. Strategic Objectives and Performance Goals and Plan Administration (Section 2107) .................................................................................................................... 53 Section 10. Annual Reports and Evaluations (Section 2108) ...................................... 62 Section 11. Program Integrity (Section 2101(a)) ........................................................... 63 Section 12. Applicant and Enrollee Protections (Sections 2101(a)) .............................. 64 Attachment 2 Referral Process ..................................................................................... 65 Attachment 10 Plan Appeal and Grievance Procedures................................................ 71 Attachment 11 Delta Dental of Iowa .............................................................................. 76 Attachment 12 Wellmark Health Plan of Iowa (WHPI) .................................................. 77 Attachment 14 hawk-i Health and Dental Plan Disaster Coverage Area ....................... 83 Attachment 15 Outreach Results ................................................................................... 84 Attachment 16 Iowa hawk-i Dental Plan ........................................................................ 87

Model Application Template for the State Children‟s Health Insurance Program

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Approval Date: 4 MODEL APPLICATION TEMPLATE FOR STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT STATE CHILDREN’S HEALTH INSURANCE PROGRAM

(Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b)))

State/Territory:____________________Iowa____________________________________ (Name of State/Territory)

As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR, 457.40(b))

________________________________________________________________________ (Signature of Governor, or designee, of State/Territory, Date Signed)

submits the following State Child Health Plan for the State Children‟s Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the approved State Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department.

The following state officials are responsible for program administration and financial oversight (42 CFR 457.40(c)): Name: Charles J. Krogmeier

Position/Title: Director, Iowa Department of Human Services Name: Jennifer Vermeer

Position/Title: Medicaid Director Name: Anita Smith

Position/Title: Chief, Bureau of Adult and Child Medical Programs

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0707. The time required to complete this information collection is estimated to average 160 hours (or minutes) per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, P.O. Box 26684, Baltimore, Maryland 21207 and to the Office of the Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503.

Model Application Template for the State Children‟s Health Insurance Program

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Approval Date: 5 Section 1. General Description and Purpose of the State Child Health Plans and State Child Health Plan Requirements (Section 2101) 1.1 The state will use funds provided under Title XXI primarily for (Check appropriate box) (42 CFR 457.70):

1.1.1

Obtaining coverage that meets the requirements for a separate child health program (Section 2103); OR

1.1.2.

Providing expanded benefits under the State‟s Medicaid plan (Title XIX); OR

1.1.3.

A combination of both of the above.

1.1-DS

The State will provide dental-only coverage. Only States operating a separate SCHIP program are eligible for this option. States choosing this option must also complete sections 1.4-DS, 4.1-DS, 4.2-DS, 4.3.1, 6.2–DS, 8.2-DS, and 9.10.1-DS of this SPA template.

Medicaid Expansion (M-CHIP) Effective July 1, 1998 Children ages 15 through 18 in families with income between 37 percent and 100 percent of Federal Poverty Level (FPL). These are the "Waxman" children that are being phased-in to Medicaid as a mandatory coverage group. Beginning October 1, 2002, all of these children will be covered under Medicaid. Children ages 6 through 18 in families with income that is equal to or less than 133 percent of FPL.

Effective July 1, 2000 Infants, up to one year of age, in families with income between 185 percent and 200 percent of FPL.

Effective July 1, 2009 When determining eligibility for infants, up to one year of age, all income between 185 percent and 300 percent of FPL shall be disregarded.

The State has implemented systems changes that allow for identification of children eligible for Medicaid via CHIP so they can be reported separately from children eligible for Medicaid via the 1902(r)(2) Medicaid State Plan

Model Application Template for the State Children‟s Health Insurance Program

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Approval Date: 6 Amendment. This will allow CHIP eligible children (optional targeted low- income children) to be reported and claimed at the enhanced rate and other newly eligible children to be reported and claimed at the State's standard FMAP. Children eligible for Medicaid as a result of the expansion receive health care services through the same delivery systems that operate in the Medicaid program.

Separate Program: Healthy And Well Kids In Iowa (hawk-i) Program (S-CHIP) The Healthy And Well Kids in Iowa (hawk-i) program covers targeted low- income children up to age 19 in families who income does not exceed 200 percent of the FPL. Effective January 1, 1999, the State implemented the hawk-i program for targeted low-income children up to age 19 in families who income was at or below 185% of the Federal Poverty Level (FPL). The State expanded coverage to 200% of the FPL effective July 1, 2000. Effective July 1, 2009, when determining eligibility, all income between 200 percent and 300 percent of the FPL shall be disregarded.

The hawk-i program has several components and is designed to encompass a variety of entry points into the program. The delivery of services follows a private sector commercial insurance model. Iowa Department of Human Services: The Department of Human Services (DHS) has been designated as the State agency to administer the hawk-i program. hawk-i Board. The Iowa General Assembly authorized the creation of the hawk-i Board to provide direction to the Department of Human Services and to establish policy for the program. The hawk-i Board is made up of eleven members: Director of the Iowa Department of Public Health or their designee Director of the Iowa Department of Education or their designee Commissioner of the Iowa Division of Insurance or their designee Four Governor-appointed public members Four ex-officio legislators (2 Senate/2 House of Representatives)

Third Party Administrator: The Department of Human Services has contracted with a third party administrator to provide, at a minimum, the following services: Distribute applications Determine eligibility

Model Application Template for the State Children‟s Health Insurance Program

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Approval Date: 7 Screen for Medicaid eligibility and coordinate with co-located Medicaid eligibility workers. Calculate, bill, and collect cost sharing. Assist the family in selecting a health plan and enrolling the child in the selected plan. Provide DHS with demographic, statistical, and encounter data for federal reporting and other reporting requirements.

Advisory Committees: Two advisory committees have been established to provide input to the hawk-i Board. The Clinical Advisory Committee is made up of health care professionals who advise the hawk-i Board on issues around benefits, access, and quality. The Children With Special Health Care Needs Advisory Committee is made up of health care professionals and advocates who advise the hawk-i Board on health care issues faced by children with special needs and make recommendations on how to address those needs. Health and Dental Plans: The Department of Human Services contracts with health and dental plans licensed by the Division of Insurance within the Department of Commerce to provide health and dental care coverage to eligible children under the hawk-i program. The University of Iowa Public Policy Center: The Department of Human Services contracts with the University of Iowa Public Policy Center to conduct analysis of the functional health assessment and analysis of the encounter data. Effective July 1, 2005, the Department of Human Services will contract with the Iowa Foundation for Medical Care to conduct the analysis of the functional health assessment and analysis of the encounter data.

1.2

Please provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d))

1.3

Please provide an assurance that the state complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. (42CFR 457.130)

1.4 Please provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this plan or plan amendment (42 CFR 457.65): Effective date: SCHIP State Plan- Medicaid Expansion 5-1-1998

Model Application Template for the State Children‟s Health Insurance Program

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Approval Date: 8 Amendment 7 Expansion of counties for Iowa Health Solutions 6-1-2003 and elimination of 6-month waiting period 7-1-2003. Amendment 8 Electronic Medicaid referral process 7-1-04, adding dental only plans 01-01-05, and withdrawal of Iowa Health Solutions 2-1-05 Amendment 9 Expansion of counties for John Deere and Delta Dental 3-1- 06 Amendment 10 Name change for John Deere Health Plan. New name is AmeriChoice from UnitedHealthcare of the River Valley (AmeriChoice) 7-1-06; Addition of Wellmark Health Plan of Iowa (WHPI) health plan 7-24-06; Expansion of WHPI counties 9-1-06; Expansion of counties for AmeriChoice and Delta Dental Plan of Iowa counties 9-15-06. Amendment 11 Expansion of counties for Wellmark Health Plan of Iowa 7-1-07 Amendment 12 Waiver of cost sharing premiums for families with countable income that equals exceeds 150% who are eligible for Iowa‟s disaster assistance for June and July 2008 - 6-1-08 Amendment 13 Increasing hawk-i income limits to 300% of the FPL. 7-1-09 Amendment 14 Coverage of Lawfully Residing Aliens 7-1-09 Withdrawal of Wellmark Blue Cross Blue Shield of Iowa (Classic Blue) 10-1-09; Name change for AmeriChoice from UnitedHealthcare of the River Valley to UnitedHealthcare of the River Valley (UHC) 11-1-09; Expansion of UHC, 3-1-10; Changes to dental benefits, 3-1-10

Implementation date: Amendment 7 Expansion of counties for Iowa Health Solutions 6-1-2003 and elimination of 6-month waiting period 7-1-2003 Amendment 8 Electronic Medicaid referral process 7-1-04, adding dental only plans 01-01-05, and withdrawal of Iowa Health Solutions 2-1-05 Amendment 9 Expansion of counties for John Deere and Delta Dental, 3-1-06 Amendment 10 Name change for John Deere Health Plan. New name is AmeriChoice from UnitedHealthcare of the River Valley (AmeriChoice) 7-1-06; Addition of Wellmark Health Plan of

Model Application Template for the State Children‟s Health Insurance Program

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Approval Date: 9 Iowa (WHPI) health plan 7-24-06; Expansion of WHPI counties 9-1-06; Expansion of counties for AmeriChoice and Delta Dental Plan of Iowa counties 9-15-06. Amendment 11 Expansion of counties for Wellmark Health Plan of Iowa. 7-1-07 Amendment 12 Waiver of cost sharing premiums for families with countable income that equals or exceeds 150% who reside are eligible for Iowa‟s disaster assistance for June and July 2008.

6-1-08 Amendment 13 Increasing hawk-i income limits to 300% of the FPL. 7-1-09 Amendment 14 Coverage of Lawfully Residing Aliens 7-1-09 Withdrawal of Wellmark Blue Cross Blue Shield of Iowa (Classic Blue) 10-1-09; Name change for AmeriChoice from UnitedHealthcare of the River Valley to UnitedHealthcare of the River Valley (UHC) 11-1-09; Expansion of UHC, 3-1-10; Changes to dental benefits, 3-1-10

1.4-DS For dental-only supplemental coverage, please provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this plan or plan amendment (42 CFR 457.65):

Effective date: 3-1-10 Implementation date: 3-1-10

Model Application Template for the State Children‟s Health Insurance Program

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Section 2. General Background and Description of State Approach to Child Health Coverage and Coordination (Section 2102 (a)(1)- (3)) and (Section 2105)(c)(7)(A)-(B))

2.1. Describe the extent to which, and manner in which, children in the state including targeted low-income children and other classes of children, by income level and other relevant factors, such as race and ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, make a distinction between creditable coverage under public health insurance programs and public- private partnerships (See Section 10 for annual report requirements). (42 CFR 457.80(a))

Historically, Iowa is a rural, agricultural state. However, recently there has been a shift in population from rural areas to urban centers. New estimates from the U.S. Census Bureau show that population growth in Iowa during the 1990's is confined to two areas: in and around Des Moines, and in the Cedar Rapids/Iowa City corridor. At the same time, 45 of Iowa's 99 counties are losing population. Data from 1994 suggests that 44 percent of Iowans live inside a metropolitan area.

According to the 2000 U.S. Census, Iowa has a population of 2,926,324 with 23.8% (827,983) being children ages 19 and younger. The Census reports show 11.5% of Iowa's population or 336,527 people living below poverty. In general, the highest levels of poverty are in the southern counties along the Missouri border.

While approximately 2,747,818 (93.9%) of Iowa's population are white and 61,423 (2.3%) are black, Iowa is experiencing an ever-emerging diverse population. For Iowa's children ages 19 years and younger, the percentages of different races varies from the total population. The children are 90.9% white, 3% black or African American, 0.4% American Indian or Alaska Native, 2% are of other race and 2.2% are two or more races. There are 36,263 Hispanic children (can be of any race) in Iowa.

Additionally, Iowa is becoming home to more and more refugees from all areas of the world. Most recently, Iowa has had significant numbers of Sudanese and Bosnians settle in some of the larger urban centers of the State.

Model Application Template for the State Children‟s Health Insurance Program

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Estimate Number of Refugees and Amerasians in Iowa Region of Origin Number Who Originally Settled in Iowa Africa

Sudanese 773 All other ethnicities 719

Near East

Iraqi 144 All Others 99

Former Soviet Union

All ethnicities 443

Eastern Europe

Bosnian 4,611 Kosovar 185 All other ethnicities 361

Southeast Asia

Vietnamese 7,383 Tai Dam 2,740 Lowland Lao 3,281 Cambodian/Khmer 840 Hmong 423

Latin America/Caribbean

Haitian 32 All other ethnicities 5

TOTAL 21,988

The Mesquaki Tribe is the only Federally recognized Native American Tribe in Iowa. It is a subset of the Sac and Fox of the Mississippi and Iowa Tribe and currently has 1,277 enrolled members. The improving economic conditions on the Mesquaki Settlement, primarily due to casino revenue, have resulted in a significant growth trend and 200% birth rate increase since 1992. According to the 2000 U.S. Census, 8,989 people identified themselves as Native American or Alaska Native. Of this number 39.1% are 19 years of age or younger.

The only public health insurance program generally available in Iowa is Medicaid. In April 2002, there were 129,192 children (66,369 male/ 62,823 female) receiving coverage through the Medicaid program.

The Iowa Caring Program for Children, a primarily privately funded, Wellmark

Model Application Template for the State Children‟s Health Insurance Program

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(Blue Cross Blue Shield of Iowa and South Dakota) sponsored program, covered about 3,000 children below 133% of FPL. This program covered uninsured children who did not qualify for Medicaid. With the expansion of Medicaid and implementation of the hawk-i program, the Caring Program ceased their program operations on July 1, 1999.

2.2. Describe the current state efforts to provide or obtain creditable health coverage for uncovered children by addressing: (Section 2102)(a)(2) (42CFR 457.80(b))

2.2.1. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in public health insurance programs (i.e., Medicaid and state-only child health insurance):

Medicaid The Medicaid program is the only public health insurance program for children in Iowa. Medicaid is administered through the Department of Human Services (DHS) Central Office in Des Moines and through 104 DHS offices (including the Refugee Services Center) located in all 99 counties. Additionally, outstationed eligibility workers are currently located at Broadlawns Hospital in Des Moines. The University of Iowa in Iowa City has 6 intake positions.

There are five Federally Qualified Health Centers (FQHC) in Iowa. Currently there is one outstationed eligibility worker position at each of these sites.

Medicaid applications are readily available to anyone who requests one. Additionally, there is a toll-free number for anyone to call and ask questions about Medicaid eligibility and to find how to apply. The number is 1-800-869-6334.

In April 2000, Iowa had 129,192 children with health care coverage through the Medicaid program. Eligibility for Medicaid continues to remain available for the following federal categories of children. Those who qualify because they would have been eligible for cash assistance prior to July 16, 1996, and related categorical programs; those who are in foster care and subsidized adoption; those who qualify for the Mothers and Children program (SOBRA); those who meet disability criteria; those who are medically needy, and those who qualify under the following home and community based waivers:

Model Application Template for the State Children‟s Health Insurance Program

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Enrollment Cap Ill and Handicapped Waiver 1660 Mental Retardation Waiver 2348(for children) + 100 ICF/MR beds Brain Injury Waiver 372 AIDS Waiver 50 Physical Disability Waiver 144 Elderly Waiver Dependent on number of clients enrolled and amount of reimbursement for clients

Health Insurance Premium Payment Program (HIPP) Iowa was one of the first states to implement the provisions of section 1906 of the Social Security Act which mandated states to purchase employer-related health insurance coverage for Medicaid-eligible persons when it was determined cost-effective to do so. Iowa implemented the Health Insurance Premium Payment (HIPP) program on July 1, 1991. Although section 1906 of the Social Security Act has now become optional, Iowa continues to maintain a strong HIPP program. Although this program is primarily designed to reduce Medicaid expenditures by providing a third party resource for Medicaid- eligible persons, oftentimes it is cost-effective to purchase family coverage which results in providing coverage for the non-Medicaid eligible household members as well. By initiating coverage while on Medicaid, families have coverage in place when they leave the Medicaid roles.

Direct Health Services (Title V, Title X, WIC, etc.) The Iowa Department of Public Health (IDPH) is the largest single provider of direct as well as support patient care for uninsured and Medicaid enrolled children and adolescents. Direct services for this population include: preventive child health services (EPSDT) and well- child check-ups, prenatal services, Women, Infants and Children Supplemental Nutrition (WIC) program services, preventive health education, immunizations, and family planning services. Support services include case coordination services, the provision of information and referral via toll-free telephone lines, and laboratory services. These services are funded through federal Title V Maternal and Child Health Block Grant funds, federal Title X Family programming funds, federal WIC Program funds, Medicaid program reimbursements, federal immunization funds, state legislative appropriations, some local government appropriations, and a small amount of patient fee revenue collected on a sliding fee scale by Title V agencies. A variety of the above direct and support services are provided within each of the 99 Iowa counties. Twenty-six Maternal

Model Application Template for the State Children‟s Health Insurance Program

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Health Centers and twenty Child Health Centers provide statewide services. Adolescent services are provided in 25 locations in the state.

Additionally, there are approximately 486 full-time school health nurses working under the auspices of the Iowa Department of Education and local education agencies in the state who provide a variety of health screening services, care coordination and emergency services.

Income assessments are performed on patients enrolled in IDPH clinics. The income assessments are reviewed for possible Medicaid eligibility. New applications, as well as annual reviews of established patients, are assessed by IDPH intake staff and/or care coordinators for possible referral for medical assistance through Medicaid and/or SSI.

In order to provide additional outreach, The IDPH operates two toll-free telephone lines for use by the general public. The toll-free telephone lines are known as Healthy Families and Teen Line. These are information and referral services for health issues. The Healthy Families line addresses a wide variety of health issues with emphasis on prenatal care. The Teen Line also addresses a variety of issues specifically related to the health of teenagers. Topics covered include drugs, sexual relationships, eating disorders, relationships with parents, and violence. Two integral parts of the information provided to callers, via these telephone lines, are information on Medicaid eligibility and referrals to community based care coordinators who can assist clients with locating local health providers who accept Medicaid-eligible children and Medicaid-eligible pregnant women. The toll-free number for Health Families is 1-800-369-2229. The Teen Line number is 1- 800-443-8336. Both lines are operational 24 hours a day, seven (7) days a week.

Child Health Specialty Clinics Each year, approximately 5,500 Iowa children receive services at the Child Health Specialty Clinics (CHSC). The Department of Human Services has an interagency cooperation agreement with the CHSC which serve as a link between major medical centers and the community by assisting families to obtain needed resources. The CHSC serves children from birth to 22 years with or at risk of a chronic health condition or disability, which includes psychosocial, physical, health-related educational, and behavioral needs. The specific health concerns may be simple or complex, short-term or long-term.

Model Application Template for the State Children‟s Health Insurance Program

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Small Group Insurance Reform Iowa enacted small group reforms in 1992. These reforms provided more affordable coverage for the small group market, thus allowing employees and their dependents to obtain coverage at more affordable rates. The reforms included limitations on rate increases as well as limitations on pre-existing condition clauses.

In 1996, Iowa implemented individual market reforms which provide for portability for employees and their dependents form a group to the individual market, as well as rating restrictions on individual products.

State High Risk Insurance Pool Iowa law established a state administered high-risk health insurance program for those individuals and their dependents who cannot obtain coverage in the private market. This program is funded by a 2% tax on health insurance premiums. Persons who are eligible for Medicaid or COBRA continuation coverage are not eligible to participate in this program. Coverage in the high-risk program provides for individuals to the private market.

2.2.2. The steps the state is currently taking to identify and enroll all uncovered children who are eligible to participate in health insurance programs that involve a public-private partnership:

Currently there are no health insurance programs that involve a public- private relationship. The Caring Program for Children There was one health insurance program in Iowa that resembled a public-private partnership. However, it was not administered by the State. This program was known as the Caring Program for Children and was administered by Wellmark (Blue Cross and Blue Shield of Iowa and South Dakota). The Iowa Caring Foundation provided ambulatory health insurance to low income, non-Medicaid/uninsured children under the age of 19 years who remain full-time students through grade 12. During its 10 years of operation, the Caring Foundation was funded through a state appropriation and private donations, with matching funds from Wellmark. At its peak the Caring Program had an enrollment of over 3000 children. The Caring Program ceased operation on June 30, 1999.

Model Application Template for the State Children‟s Health Insurance Program

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2.3. Describe the procedures the state uses to accomplish coordination of SCHIP with other public and private health insurance programs, sources of health benefits coverage for children, and relevant child health programs, such as title V, that provide health care services for low-income children to increase the number of children with creditable health coverage. (Previously 4.4.5.) (Section 2102)(a)(3) and 2102(c)(2) and 2102(b)(3)(E)) (42CFR 457.80(c))

At the time a child is determined not to be eligible for hawk-i, the letter the applicant receives states: "Although you child does not qualify for hawk-i, health care services may be available through your local child health agency. For information about the child health center in your area, please call 1-800- 369-2229 (Iowa Healthy Families Information and Referral Service)."

When it is determined that a child does not qualify or will no longer qualify for Medicaid due to excess income, a referral is made to hawk-i. The referral can be accomplished either electronically or using a paper form. In either format, the referral includes the name of the child (or children), the Medicaid application date (for children denied Medicaid) or the Medicaid end date (for children cancelled from Medicaid), and the reason for the referral. The electronic referral also includes the income amounts used to determine Medicaid ineligibility. A copy of the Medicaid notice of decision denying or cancelling Medicaid accompanies the paper referral. This notice contains a calculation showing how Medicaid ineligibility due to excess income was determined.

The third party administrator performs a comparison of hawk-i enrollees to Medicaid enrollees. A file containing the Medicaid enrollees is received and matched daily with the hawk-i enrollee file. If a match is found, the child is cancelled from hawk-i after being given notice of the cancellation.

If an individual applying for health services through a public health clinic also wishes to apply for Medicaid or hawk-i, the public health clinic will forward this information to hawk-i within two working days.

If an individual applying for WIC services also wishes to apply for Medicaid, the WIC agency will forward the information to Medicaid. If an individual applying for WIC appears to qualify for hawk-i, the individual is given a hawk-i enrollment form.

If a child applying for hawk-i is determined to be eligible for Medicaid, a referral for EPSDT is made. If a child or family asks about WIC, a WIC brochure along with the location of the nearest WIC is given to them.

Model Application Template for the State Children‟s Health Insurance Program

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In the action plans of the Title V agencies in Iowa, the Title V agencies have included outreach to hawk-i and Medicaid to children who may be eligible. The agencies will identify these children, notify the families of the program and advise them where and how to enroll and how to maintain the enrollment.

The Iowa Department of Human Services will be entering into a contract with the Iowa Department of Public Health to conduct grassroots outreach for the hawk-i and Medicaid programs. The Iowa Department of Public Health who oversees the Title V agencies, will ask the Title V agencies to either conduct the grassroots outreach activities or to subcontract with an agency or organization to do outreach. The Title V agencies will be responsible for doing a gap analysis to see what community agencies are currently doing for outreach as well as determine what is missing. The action plans must include the results of the gap analysis and what steps the agency will take to involve the community in conducting outreach.

Model Application Template for the State Children‟s Health Insurance Program

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Section 3. Methods of Delivery and Utilization Controls (Section 2102)(a)(4))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state‟s Medicaid plan, and continue on to Section 4.

3.1. Describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of the choice of financing and the methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102)(a)(4) (42CFR 457.490(a))

Healthy And Well Kids in Iowa (hawk-i) Program The State has entered into contractual agreements with commercial insurers to provide a benchmark equivalent benefit package to enrollees in the hawk-i program. The insurer will provide the enrollee with a health plan card identifying them as an enrollee in that health plan. The enrollee will have a primary care physician if they are in a managed care plan.

Both indemnity and managed care plans are allowed to participate in the program. The goal is to allow choice among plans so that enrollees can select the health plan from which they want to receive coverage. Both indemnity and managed care plans receive a monthly capitation payment for each hawk-i enrollee in the plan. The State contracts with indemnity plans only in those counties where the State does not have a contract with a managed care plan. If the State enters into a contract with a managed care plan in a county where the State currently has a contract with an indemnity plan, the hawk-i enrollees of the indemnity plan shall remain enrolled with the indemnity plan until the expiration of the twelve-month enrollment. All enrollees eligible for the hawk-i program after the execution of the contract with the managed care plan shall be enrolled with the managed care plan.

Effective July 1, 2003, the Iowa legislature passed legislation that allows dental only carriers to participate in the hawk-i program. Effective July 1, 2009, hawk-i dental services are provided through a separate dental plan, Delta Dental of Iowa. Participating health plans are no longer offering dental coverage.

A child shall remain enrolled in a health and dental plan for a twelve-month period unless: a request for disenrollment from the plan is made at any time for cause; a request for disenrollment from the plan is made without cause during the

Model Application Template for the State Children‟s Health Insurance Program

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90 days following the date of initial enrollment or when the third party administrator sends the notice of enrollment to the enrollee whichever is later; there is a substantial change in the provider network of the health or dental plan originally chosen. A substantial change is determined by the hawk-i Board and means, but is not limited to, loss of a contracted hospital or provider group. When there is another participating health or dental plan available in the child‟s county of residence, the child may disenroll from the current health or dental plan and enroll in the other health or dental plan for the remainder of the twelve-month period.

A child may disenroll from a health or dental plan at least every 12 months at the time of renewal.

3.2. Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children. Describe the systems designed to ensure that enrollees receiving health care services under the state plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved state plan. (Section 2102)(a)(4) (42CFR 457.490(b))

Healthy And Well Kids in Iowa (hawk-i) Program Health and dental plans are allowed to establish limits for services and implement utilization management guidelines such as requiring prior authorization and using drug formularies as long as the plan provides the required services and meets benchmark equivalency. Plans may not deny coverage due to the existence of a pre-existing medical condition.

The State conducts periodic evaluations of each health plan for the purpose of reviewing the policies and procedures for utilization management, appeals and grievances, contract compliance, health education programs and materials, and the quality improvement program

Model Application Template for the State Children‟s Health Insurance Program

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Section 4. Eligibility Standards and Methodology. (Section 2102(b))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state‟s Medicaid plan, and continue on to Section 5. 4.1. The following standards may be used to determine eligibility of targeted low- income children for child health assistance under the plan. Please note whether any of the following standards are used and check all that apply. If applicable, describe the criteria that will be used to apply the standard. (Section 2102)(b)(1)(A)) (42CFR 457.305(a) and 457.320(a)) 4.1-DS A child who is eligible to enroll in dental-only supplemental coverage, effective January 1, 2009. Eligibility is limited to only targeted low-income children who are otherwise eligible for CHIP but for the fact that they are enrolled in a group health plan or health insurance offered through an employer. The State‟s SCHIP plan income eligibility level must be at least 200 percent of the FPL as of January 1, 2009. All who meet the eligibility standards and apply for dental-only supplemental coverage shall be provided benefits. States choosing this option must report these children separately in SEDS.

4.1.1.

Geographic area served by the Plan:

Effective July 1, 2009: Wellmark Health Plan of Iowa (WHPI) is providing health care coverage in all Iowa Counties: Delta Dental of Iowa is providing dental care coverage in all Iowa counties. WHPI and Classic Blue are no longer providing dental care coverage. UnitedHealthcare is providing health care coverage in the following 53 Iowa counties:

Iowa Counties Appanoose Clinton Iowa Lucas Wapello Black Hawk Dallas Jackson Madison Warren Benton Davis Jasper Marion Washington Boone Delaware Jefferson Monroe Wayne Bremer Dubuque Johnson Muscatine

Buchanan Fayette Jones Polk

Butler Greene Keokuk Poweshiek

Carroll Grundy Lee Scott

Cedar Guthrie Linn Story

Clayton Henry Louisa Van Buren

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Effective October 1, 2009: Classic Blue (Wellmark Blue Cross Blue Shield of Iowa) is no longer participating with the hawk-i program.

Effective March 1, 2010: UnitedHealth care is providing health care coverage in all Iowa counties.

See Attachment 13 for a map showing the counties and the corresponding health and dental plans.

4.1.2.

Age: Under hawk-i, children up to the age of 19 are covered. Coverage ends effective the first day of the month following the month of the nineteenth birthday. 4.1.3.

Income: Effective July 1, 2000, under hawk-i, countable earned and gross unearned income cannot exceed 200% of the FPL for family of the same size. Effective December 1, 1999, 20% of earned income (including self-employment income) will be exempt when determining family income for the hawk-i program. Effective February 1, 2000, income from self-employment: under hawk-i, income from self-employment will be the gross income minus the cost of doing business. This includes the depreciation of capital assets as identified for income tax purposes. Effective July 1, 2009, when determining eligibility, all income between 200 percent and 300 percent of the FPL shall be disregarded. 4.1.4.

Resources (including any standards relating to spend downs and disposition of resources): 4.1.5.

Residency (so long as residency requirement is not based on length of time in state): Iowa. There is no minimum period of time in which the child must reside in the State to establish residency. A resident is one: a. Who is living in Iowa voluntarily with the intention of making that person's home in Iowa and not for a temporary purpose; or b. Who, at the time of application, is not receiving assistance from another state and entered Iowa with a job commitment or to seek employment or who is living with parents or guardians who entered Iowa with a job commitment or to seek employment. 4.1.6.

Disability Status (so long as any standard relating to disability

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status does not restrict eligibility): 4.1.7.

Access to or coverage under other health coverage: A child who is covered under other health insurance is not eligible for coverage under hawk-i unless the coverage is a single service coverage such as a dental only or vision only policy. Access to coverage is not considered if the child is not actually covered. 4.1.8.

Duration of eligibility: Eligibility for hawk-i is granted in 12-month enrollment periods. At the end of the 12 months, a review is completed to establish eligibility for the next 12-month enrollment period. 4.1.9.

Other standards (identify and describe): Pregnancy. During the 12-month enrollment cycle, if an adolescent enrolled in the hawk-i program becomes pregnant, information about the Medicaid program is provided to the pregnant adolescent or her family. However, the pregnant child is not automatically transferred to the Medicaid program. If the adolescent or her family applies for Medicaid and Medicaid eligibility is approved, hawk-i eligibility ends. If the child or her family do not apply for Medicaid, eligibility will continue under hawk-i until the next annual renewal. If, at the next annual renewal, the adolescent is still pregnant, the renewal is referred to Medicaid for a Medicaid eligibility determination. Inmates of nonmedical public institution. At the time of application or annual review of eligibility, the child shall not be an inmate of a nonmedical public institution as defined at 42 CFR Section 435.1009 as amended November 10, 1994. Inmates of institutions for mental disease. At the time of application or annual review of eligibility, the child shall not be an inmate of an institution for mental as defined at 42 CFR 435 Section 435.1009 as amended November 10, 1994.

4.1.10 __X___ Check if the State is electing the option under section 214 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) to provide coverage to the following otherwise eligible and children as specified below who are lawfully residing in the United States including the following: A child shall be considered lawfully present if he or she is: (1) A qualified alien as defined in section 431 of PRWORA (8 U.S.C. §1641); (2) An alien in nonimmigrant status who has not violated the terms of the status under which he or she was admitted or to which he or she has changed after admission;

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(3) An alien who has been paroled into the United States pursuant to section 212(d)(5) of the Immigration and Nationality Act (INA) (8 U.S.C. §1182(d)(5)) for less than 1 year, except for an alien paroled for prosecution, for deferred inspection or pending removal proceedings; (4) An alien who belongs to one of the following classes: (i) Aliens currently in temporary resident status pursuant to section 210 or 245A of the INA (8 U.S.C. §§1160 or 1255a, respectively); (ii) Aliens currently under Temporary Protected Status (TPS) pursuant to section 244 of the INA (8 U.S.C. §1254a), and pending applicants for TPS who have been granted employment authorization; (iii) Aliens who have been granted employment authorization under 8 CFR 274a.12(c)(9), (10), (16), (18), (20), (22), or (24); (iv) Family Unity beneficiaries pursuant to section 301 of Pub. L. 101-649, as amended; (v) Aliens currently under Deferred Enforced Departure (DED) pursuant to a decision made by the President; (vi) Aliens currently in deferred action status; or (vii) Aliens whose visa petition has been approved and who have a pending application for adjustment of status; (5) A pending applicant for asylum under section 208(a) of the INA (8 U.S.C. § 1158) or for withholding of removal under section 241(b)(3) of the INA (8 U.S.C. § 1231) or under the Convention Against Torture who has been granted employment authorization, and such an applicant under the age of 14 who has had an application pending for at least 180 days; (6) An alien who has been granted withholding of removal under the Convention Against Torture; (7) A child who has a pending application for Special Immigrant Juvenile status as described in section 101(a)(27)(J) of the INA (8 U.S.C. § 1101(a)(27)(J)); (8) An alien who is lawfully present in the Commonwealth of the Northern Mariana Islands under 48 U.S.C. § 1806(e); or (9) An alien who is lawfully present in American Samoa under the immigration laws of American Samoa. X_ The State elects the CHIPRA section 214 option for children up to age 19 _____The State elects the CHIPRA section 214 option for pregnant women through the 60-day postpartum period

4.1.10.1__X___ The State provides assurance that for individuals whom it enrolls in

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CHIP under the CHIPRA section 214 option that it has verified, both at at the time of the individual’s initial eligibility determination and at the time of the eligibility redetermination, that the individual continues to be lawfully residing in the United States. The State must first attempt to verify this status using information provided at the time of initial application. If the State cannot do so from the information readily available, it must require the individual to provide documentation or further evidence to verify satisfactory immigration status in the same manner as it would for anyone else claiming satisfactory immigration status under section 1137(d) of the Act.

4.2. The state assures that it has made the following findings with respect to the eligibility standards in its plan: (Section 2102)(b)(1)(B)) (42CFR 457.320(b)) 4.2.1.

These standards do not discriminate on the basis of diagnosis. 4.2.2.

Within a defined group of covered targeted low-income children, these standards do not cover children of higher income families without covering children with a lower family income. 4.2.3.

These standards do not deny eligibility based on a child having a pre-existing medical condition.

4.2-DS For dental-only supplemental coverage, the State assures that it has made the following findings with respect to the eligibility standards in its plan: (Section 2102)(b)(1)(B)) (42CFR 457.320(b))

4.2.1-DS These standards do not discriminate on the basis of diagnosis. 4.2.2-DS Within a defined group of covered targeted low-income children, these standards do not cover children of higher income families without covering children with a lower family income. 4.2.3-DS These standards do not deny eligibility based on a child having a pre-existing medical condition.

4.3. Describe the methods of establishing eligibility and continuing enrollment. (Section 2102)(b)(2)) (42CFR 457.350) Initial Enrollment Applications for the hawk-i program are received via mail, fax, or on-line through the hawk-i web site by the third party administrator at a central location in Des Moines, Iowa. Applications are screened for completeness of information, the presence of other health insurance, verification of income, the presence of State of Iowa employment, and Medicaid eligibility. If it appears that a child is Medicaid eligible, the application is referred to a Medicaid eligibility worker co-located at the third party administrator's office for a Medicaid eligibility determination. (See Attachment 2)

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Upon receipt of a completed application, the third party administrator must determine hawk-i eligibility within 10 working days. If it is determined the child is uninsured, that countable income does not exceed the hawk-i limit, and that the child otherwise qualifies, a notice of approval is sent to the family. Included with the approval notice is information about the health and dental plans available to the family and a Plan Selection form on which the family must make their selection. If countable income exceeds 150% of FPL but does not exceed 200 % of FPL, the family is also required to pay a premium of $10 per month per child, not to exceed $20 per month, regardless of family size. If countable income exceeds 200% of FPL but does not exceed 300% of FPL, the family is required to pay a premium of $20 per month per child, not to exceed $40 per month, regardless of family size. Cost sharing is not assessed to American Indian or Alaska Native children, regardless of income. Upon approval of an initial application, the first month for which a premium will be due is the third month following the month in which the approval letter was sent to the applicant. The first premium shall be due on the 10th calendar day of the second month following the month in which the approval letter was sent to the applicant. Note: An “initial application” is an application that is not an annual renewal. For the months of June 2008 and July 2008, the premiums for families with countable income that equals or exceeds 150% of FPL are waived. The basis for this waiver is good cause due to the financial hardship for those families with limited income in any of the Iowa counties that have been declared a disaster by the Governor of Iowa and/or Presidential Declaration of Disaster for Individual Assistance. See Attachment 14 for the list of Iowa counties effected as of June 30, 2008. Upon receipt of the Plan Selection form, the third party administrator notifies the health plan of the new enrollment. If the Plan Selection form is not returned by the due date, the third party administrator randomly assigns the family to a health plan. The family has thirty days to notify the third party administrator if they want to change the health plan. The health plan provides an identification card, an explanation of coverage, and a list of participating providers to the family.

Ongoing Eligibility During the 12-Month Enrollment Once eligibility is established, the child shall remain enrolled in the hawk-i program for a 12-month enrollment period unless one of the following occurs: a. The child moves to an area of the state not served by that plan. In which case, the child shall be enrolled in a participating plan in the new location. The enrollment period is the remaining months of the original 12-month enrollment. b. Age. The child shall be disenrolled from the hawk-i program as of the first

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day of the month following the month of the nineteenth birthday. c. Nonpayment of premiums. The child shall be disenrolled as of the first day of the month following the month in which premiums are not paid. If the family reports a decrease in income during the 12-month enrollment period, premium cost sharing is re-evaluated. If the family's income is reduced below 150 percent of FPL, the family will not have to pay a premium for the remaining months of the enrollment period. d. Iowa residence is abandoned. The child shall be disenrolled from the plan and canceled from the program as of the first day of the month following the month in which the child relocated to another state. e. Medicaid eligibility. The child shall be disenrolled from the plan and canceled from the program as of the first day of the month following the month in which Medicaid eligibility is attained. f. Enrolled in other health insurance. The child shall be disenrolled from the plan as of the first day of the month following the month in which the child attains other health insurance coverage. g. Admission to a nonmedical public institution. The child shall be disenrolled from the plan and canceled from the program as of the first day of the month in which the child enters a nonmedical public institution unless it can be established that the absence is temporary. h. Employment with the State of Iowa. The child shall be disenrolled from the plan and canceled from the hawk-i program as of the first day of the month in which the child's parent becomes eligible to participate in a health plan available to State of Iowa employees.

Recertification All eligibility factors are reviewed annually as follows: a. Sixty (60) days prior to the end of the 12-month enrollment period, the third party administrator mail a hawk-i renewal application form to the family. The renewal application form is preprinted with the information known about the household. The family is asked to verify the correctness of the information and return the corrected form with current income verification. A postage-paid return envelope is provided. b. If the family fails to return the information or required income verification, the child shall not be recertified for the next 12-month enrollment period. c. Upon a determination that the child continues to meet all eligibility factors, the family shall be allowed to select another plan for the next 12-month enrollment period if another plan is available. If the family does not select another plan, the child shall be re-enrolled with the current plan for the next 12-month enrollment period.

4.3.1 Describe the state‟s policies governing enrollment caps and waiting lists (if any). (Section 2106(b)(7)) (42CFR 457.305(b))

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Check here if this section does not apply to your state. A State providing dental-only supplemental coverage may not have a waiting list or limit eligibility in any way.

4.4. Describe the procedures that assure that: 4.4.1. Through the screening procedures used at intake and follow-up eligibility determination, including any periodic redetermination, that only targeted low-income children who are ineligible for Medicaid or not covered under a group health plan or health insurance coverage (including a state health benefits plan) are furnished child health assistance under the state child health plan. (Section 2102)(b)(3)(A)) (42CFR 457.350(a)(1) and 457.80(c)(3))

Refer to response in 4.3.

4.4.2. The Medicaid application and enrollment process is initiated and facilitated for children found through the screening to be potentially eligible for medical assistance under the state Medicaid plan under Title XIX. (Section 2102)(b)(3)(B)) (42CFR 457.350(a)(2))

Refer to response in 4.3.

4.4.3. The State is taking steps to assist in the enrollment in SCHIP of children determined ineligible for Medicaid. (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42CFR 431.636(b)(4))

Refer to response in 4.3.

4.4.4 The insurance provided under the state child health plan does not substitute for coverage under group health plans. Check the appropriate box. (Section 2102)(b)(3)(C)) (42CFR 457.805) (42 CFR 457.810(a)-(c))

4.4.4.1. Coverage provided to children in families at or below 200% FPL: describe the methods of monitoring substitution.

A child who is currently enrolled in an individual or group health plan is not eligible to participate in the hawk-i program. Exception: A child who is enrolled in a single service plan that provides coverage only for a specific disease or service (e.g. dental only or vision only) is

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considered uninsured for the purpose of establishing hawk-i eligibility. Effective July 1, 2003, the State no longer imposes a 6- month waiting period for children who have been insured through an employer group health plan in the six months prior to the month of application. Iowa House File 565 included provisions that require the Department to monitor the effects of eliminating the 6-month waiting period and report back to the General Assembly on the findings. The state is continuing to ask insurance history questions on the application form and the information is being tracked by the state's third party administrator. A quarterly report will identify the impact of this change on the program and be reported to the General Assembly.

4.4.4.2. Coverage provided to children in families over 200% and up to 250% FPL: describe how substitution is monitored and identify specific strategies to limit substitution if levels become unacceptable. See response to 4.4.4.3

4.4.4.3. Coverage provided to children in families above 250% FPL: describe how substitution is monitored and identify specific strategies in place to prevent substitution.

A match with insurance carriers is done at application to determine if the child has other health insurance. The report indicates if there is other health coverage, the effective date of the coverage and the date the coverage ended if applicable. To be eligible, a child whose family‟s income is from 251 to 300% FPL, must not have dropped health insurance coverage in the month prior to the month in which the child would otherwise be eligible. If health insurance was dropped, the effective date of the hawk-i coverage will be delayed by one (1) month. Children who have lost health insurance coverage due to one of the following reasons will not be subject to the one (1) month waiting period. 1. The child is moving from Medicaid to hawk-i. 2. The child has a chronic or emergent medical condition. 3. The cost of the health care coverage for the child

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exceeded 5% of the family‟s gross income. Cost of the health care coverage for the child shall be the difference between the premium for coverage with and without the child. 4. The health care coverage was provided through an individual plan. 5. The child‟s health care coverage was lost due to: a. Domestic violence b. Divorce or death of a parent c. An involuntary loss of the parent‟s employment, including, but not limited to layoff, business closure, reduction in hours, termination, etc. d. A change in the parent‟s employer to one who does not offer dependent coverage or requires a waiting period longer than 30 days before the child can be enrolled. e. The child reached the maximum lifetime coverage benefit. f. Expiration of coverage under COBRA. g. The parent‟s employer discontinuing the availability of dependent coverage. h. A reason beyond the control of the parent such as serious illness of the parent, natural disaster, fire, flood, etc.

4.4.4.4. If the state provides coverage under a premium assistance program, describe: The minimum period without coverage under a group health plan, including any allowable exceptions to the waiting period. The minimum employer contribution. The cost-effectiveness determination.

4.4.5 Child health assistance is provided to targeted low-income children in the state who are American Indian and Alaska Native. (Section 2102)(b)(3)(D)) (42 CFR 457.125(a))

American Indian and Alaska Native Children are eligible for the hawk-i program on the same basis as any other children in the State, regardless of whether or not they may be eligible for or served by Indian Health Services-funded care. No premiums or other cost sharing apply to American Indian or Alaska Native children.

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Section 5. Outreach (Section 2102(c))

Describe the procedures used by the state to accomplish: Outreach to families of children likely to be eligible for child health assistance or other public or private health coverage to inform them of the availability of the programs, and to assist them in enrolling their children in such a program: (Section 2102(c)(1)) (42CFR 457.90) Outreach to families of children likely to be eligible for child health assistance or other public or private health coverage to inform them of the availability of the programs, and to assist them in enrolling their children in such a program: (Section 2102(c)(1)) (42CFR 457.90) Outreach to families of children likely to be eligible for child health assistance or other public or private health coverage to inform them of the availability of the programs, and to assist them in enrolling their children in such a program: (Section 2102(c)(1)) (42CFR 457.90)

Grassroots Outreach In July of 1999, the hawk-i Board directed the Iowa Department of Human Services to develop a grassroots outreach effort. The Department developed a plan by which communities would bring together those individuals and entities that touch the lives of families with children in order to develop a community outreach strategy. Once the plan was developed, it was submitted to the Department for approval and funding was made available to assist in the implementation plan. Currently, the Department has 53 community outreach contracts that cover 89 counties.

Covering Kids Grant Project: Covering Kids is a 3-year grant that was awarded to the Iowa Department of Public Health in 1999 by the Robert Wood Johnson Foundation. The purpose of the grant is to increase access to health care coverage for all uninsured and underinsured children in Iowa. Administrators of the grant work collaboratively with the Iowa Department of Human Services, the Iowa Department of Education, advocates, medical providers, and others to address barriers to access for uninsured and underinsured children. This grant expires on June 30, 2002. As of July 1, 2002, the Iowa Department of Public Health will continue this work under a new 4-year Robert Wood Johnson Covering Kids and Families grant.

Mass Media Campaign During the spring of 2001, a short-term mass media campaign was used.

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Television commercials that had been produced for the national Insure Kids Now effort were used. Commercials were aired in both English and Spanish. Also a 60-second radio commercial in English and Spanish was produced. The commercials were aired for a seven-week period during March, April and May. There was an immediate response to the media campaign. During the six-month period prior to the campaign, the hawk-i customer service center received an average of 400 application requests per month. During the three months in which the commercials aired, application requests averaged 1,500 per month.

Other Media Ads have been placed in the Qwest Dex directory, in the yellow pages as well as the internet listing hawk-i 's toll free number. Ads have also occurred in various local and state newsletters, magazines, and other publications.

Partnering with Schools The Department of Human Services and the Department of Education collaborated to develop an interagency agreement that allowed schools and child care providers who participate in the Free and Reduced Meals Program to make referrals to the hawk-i Program for outreach purposes. Under this initiative, the names of applicants for the Free and Reduced Meals Program are referred to the hawk-i Program unless the family specifically asks not to be referred. Participating schools submitted a list of names to the hawk-i customer service center and then the customer service center mailed an application and information to the families. During the first year of this effort, applications were mailed to approximately 6,000 families. The Departments are working together to ensure this will be an ongoing effort.

Literacy Project Iowa was one of seven states selected to participate in a literacy project being conducted by the Centers for Medicare and Medicaid Services. The purpose of the project was to evaluate applications, brochures and other state- produced materials to assess how they could be modified to ensure comprehension by persons with very low literacy levels. Additionally, materials written in non-English languages were evaluated to see if they would meet the needs of the populations for which they were intended. These findings are being utilized in the study to redesign the hawk-i application and brochure in order to remove as many barriers to enrollment as possible.

Multi-Language Poster The Department of Human Services introduced a new multi-language hawk-i poster in October 2001 in order to ensure that the needs of persons with

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limited English proficiency were being met. The poster provides information about the program in five languages: English, Spanish, Bosnian, Vietnamese, and Laotian. It also informs that translator services are available to assist them applications. The need for translation of information into these specific languages was identified through input of local outreach workers, the Bureau of Refugee Services, and use of AT&T translator lines by the hawk-i customer service center.

Corporate Involvement Nationally, there has been a growing interest by large corporations to assist states in promoting their SCHIP Program. Iowa actively takes advantage of these efforts to further promote the program. Some of these efforts in Iowa included:  Wal-Mart/Pampers  H&R Block  The Marmaxx In addition to the outreach activities aimed at enrolling eligible children, the state agencies' existing efforts to promote the use of health care services and continuity of care will also be expanded to include the new Title XXI enrollees. These activities include use of the media, case management, and patient follow-up systems, (especially within the Title V, Title X and Title XX Block Grant Programs, and related programs for children within the Iowa Department of Human Services).

Case management consists of a variety of activities designed to identify an individual patient's psychosocial needs and barriers to obtaining health services (such as enrolling in Medicaid), and assist the patient in meeting those needs and accessing services. Patient follow-up includes a variety of activities designed to ensure that patients comply with the recommendations of their health care provider(s) and continue in the health system.

One example of Iowa's continuing effort to improve the health status of school-aged children, the Project Success Program, coordinates social and health services with parental involvement in 13 designated school sites in the Des Moines school district. Project Success sites, which include seven elementary schools, two middle schools, two high schools, and two alternative high schools, refer potentially eligible Medicaid children for eligibility determination. Additionally, sixteen schools based/linked clinics provide services to school-aged children, their siblings and preschool aged children in the district. The clinics are required to assess income levels and refer those children who appear to be Medicaid eligible for eligibility determination while at the same time providing needed medical services.

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Outreach Activities from 2006 to present: Media Campaign: In September 2007, the DHS entered into a contract with ZLRIGNITION (ZLR), a media buyer, to develop a media campaign for the hawk-i and Medicaid program. ZLR conducted focus awareness groups of the hawk-i program. Based on the results of the focus groups, ZLR developed television, radio and print ads that focused on working families who do not have health insurance for their children. See Attachment 15 for results.

Income Tax Match: In September 2008, DHS began working with the Iowa Department of Revenue to add a question to the Iowa 2008 tax forms for families about health care coverage for their children. Families who answered the question with no my children do not have health care coverage and who‟s income was within the federal poverty were sent a hawk-i application by the Department of Revenue. This process will be further refined for the 2009 tax season. See Attachment 15 for results.

Outreach in local communities: In July 2006, DHS entered into contract with the Iowa Department of Public Health (IDPH) to conduct outreach in local communities. IDPH subcontracts with their Title V agencies for outreach activities. Such activities include, but are not limited to: health fair presentations, contacting local church and business and back to school registrations.

Free and Reduced Meals: In the 2007 Iowa legislative session, schools are mandated to provide names of children who participate in the free and reduced meal program as listed above in “Partnering with Schools”. Each year the process is further refined to make this process easier. DHS has also expanded this effort to include day care and preschools in addition to schools.

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Section 6. Coverage Requirements for Children’s Health Insurance (Section 2103)

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state‟s Medicaid plan, and continue on to Section 7.

6.1. The state elects to provide the following forms of coverage to children: (Check all that apply.) (42CFR 457.410(a))

6.1.1.

Benchmark coverage; (Section 2103(a)(1) and 42 CFR 457.420)

6.1.1.1. FEHBP-equivalent coverage; (Section 2103(b)(1)) (If checked, attach copy of the plan.) 6.1.1.2. State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan and attach a copy of the benefits description.) 6.1.1.3. HMO with largest insured commercial enrollment (Section 2103(b)(3)) (If checked, identify the plan and attach a copy of the benefits description.)

6.1.2.

Benchmark-equivalent coverage; (Section 2103(a)(2) and 42 CFR 457.430) Specify the coverage, including the amount, scope and duration of each service, as well as any exclusions or limitations. Please attach a signed actuarial report that meets the requirements specified in 42 CFR 457.431. See instructions.

See Attachment 3 for the benchmark plan. Effective October 1, 2009, the following health plans are participating in the hawk-i program. UnitedHealthcare Plan of the River Valley Wellmark Health Plan of Iowa

6.1.3.

Existing Comprehensive State-Based Coverage; (Section 2103(a)(3) and 42 CFR 457.440) [Only applicable to New York; Florida; Pennsylvania] Please attach a description of the benefits package, administration, date of enactment. If existing comprehensive state-based coverage is modified, please provide an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of 8/5/97 or one of the benchmark plans. Describe the fiscal year 1996 state expenditures for existing comprehensive state-based coverage.

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6.1.4.

Secretary-Approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450)

6.1.4.1. Coverage the same as Medicaid State plan 6.1.4.2. Comprehensive coverage for children under a Medicaid Section 1115 demonstration project 6.1.4.3. Coverage that either includes the full EPSDT benefit or that the state has extended to the entire Medicaid population 6.1.4.4. Coverage that includes benchmark coverage plus additional coverage 6.1.4.5. Coverage that is the same as defined by existing comprehensive state-based coverage 6.1.4.6. Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Please provide a sample of how the comparison will be done) 6.1.4.7. Other (Describe)

6.2. The state elects to provide the following forms of coverage to children: (Check all that apply. If an item is checked, describe the coverage with respect to the amount, duration and scope of services covered, as well as any exclusions or limitations) (Section 2110(a)) (42CFR 457.490)

6.2.1.

Inpatient services (Section 2110(a)(1)) 6.2.2.

Outpatient services (Section 2110(a)(2)) 6.2.3.

Physician services (Section 2110(a)(3)) 6.2.4.

Surgical services (Section 2110(a)(4)) 6.2.5.

Clinic services (including health center services) and other ambulatory health care services. (Section 2110(a)(5)) 6.2.6.

Prescription drugs (Section 2110(a)(6)) 6.2.7.

Over-the-counter medications (Section 2110(a)(7)) 6.2.8.

Laboratory and radiological services (Section 2110(a)(8)) 6.2.9.

Prenatal care and prepregnancy family services and supplies (Section 2110(a)(9)) 6.2.10.

Inpatient mental health services, other than services described in 6.2.18., but including services furnished in a state-operated mental hospital and including residential or other 24-hour therapeutically planned structural services (Section 2110(a)(10)) 6.2.11.

Outpatient mental health services, other than services described in 6.2.19, but including services furnished in a state-operated mental hospital and including community-based services

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(Section 2110(a)(11) 6.2.12.

Durable medical equipment and other medically-related or remedial devices (such as prosthetic devices, implants, eyeglasses, hearing aids, dental devices, and adaptive devices) (Section 2110(a)(12)) 6.2.13.

Disposable medical supplies (Section 2110(a)(13)) 6.2.14.

Home and community-based health care services (See instructions) (Section 2110(a)(14)) 6.2.15.

Nursing care services (See instructions) (Section 2110(a)(15)) 6.2.16.

Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16) 6.2.17.

Dental services (Section 2110(a)(17)) Refer to 6.2.-D for details. 6.2.18.

Inpatient substance abuse treatment services and residential substance abuse treatment services (Section 2110(a)(18)) 6.2.19.

Outpatient substance abuse treatment services (Section 2110(a)(19)) 6.2.20.

Case management services (Section 2110(a)(20)) 6.2.21.

Care coordination services (Section 2110(a)(21)) 6.2.22.

Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders (Section 2110(a)(22)) 6.2.23.

Hospice care (Section 2110(a)(23)) 6.2.24.

Any other medical, diagnostic, screening, preventive, restorative, remedial, therapeutic, or rehabilitative services. (See instructions) (Section 2110(a)(24)) 6.2.25.

Premiums for private health care insurance coverage (Section 2110(a)(25)) 6.2.26.

Medical transportation (Section 2110(a)(26)) 6.2.27.

Enabling services (such as transportation, translation, and outreach services (See instructions) (Section 2110(a)(27)) 6.2.28.

Any other health care services or items specified by the Secretary and not included under this section (Section 2110(a)(28))

6.2.-DS The State will provide dental coverage to children eligible for dental-only supplemental services. Children eligible for this option must receive the same dental services as provided to otherwise eligible CHIP children (Section 2103(a)(5):

6.2.-D The State will provide dental coverage to children through one of the following. Dental services provided to children eligible for dental-only supplemental services must receive the same dental services as provided to

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otherwise eligible CHIP children (Section 2103(a)(5)): 6.2.1.-D State Specific Dental Benefit Package. The State assures dental services represented by the following categories of common dental terminology (CDT) codes are included in the dental benefits: 1. Diagnostic (i.e., clinical exams, x-rays) (CDT codes: D0100-D0999) (must follow periodicity schedule) 2. Preventive (i.e., dental prophylaxis, topical fluoride treatments, sealants) (CDT codes: D1000-D1999) (must follow periodicity schedule) 3. Restorative (i.e., fillings, crowns) (CDT codes: D2000-D2999) 4. Endodontic (i.e., root canals) (CDT codes: D3000-D3999) 5. Periodontic (treatment of gum disease) (CDT codes: D4000-D4999) 6. Prosthodontic (dentures) (CDT codes: D5000-D5899, D5900-D5999, and D6200-D6999) 7. Oral and Maxillofacial Surgery (i.e., extractions of teeth and other oral surgical procedures) (CDT codes: D7000-D7999) 8. Orthodontics (i.e., braces) (CDT codes: D8000-D8999) 9. Emergency Dental Services

6.2.1.2-D Periodicity Schedule. The State has adopted the following periodicity schedule: State-developed Medicaid-specific American Academy of Pediatric Dentistry Other Nationally recognized periodicity schedule Other (description attached)

See Attachment 16 for the Iowa hawk-i Dental Plan

6.2.2-D Benchmark coverage; (Section 2103(c)(5), 42 CFR 457.410, and 42 CFR 457.420)

6.2.2.1.-D FEHBP-equivalent coverage; (Section 2103(c)(5)(C)(i)) (If checked, attach copy of the dental-only supplemental plan benefits description and the applicable CDT codes. If the State chooses to provide supplemental services, please also attach a description of the services and applicable CDT codes)

6.2.2.2-D State employee coverage; (Section 2103(c)(5)(C)(ii)) (If checked, identify the plan and attach a copy of the benefits description and the applicable CDT codes. If the State chooses to provide supplemental services, please also attach a description of the services and applicable CDT codes)

6.2.2.3.-D HMO with largest insured commercial enrollment (Section

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2103(c)(5)(C)(iii)) (If checked, identify the plan and attach a copy of the benefits description and the applicable CDT codes. If the State chooses to provide supplemental services, please also attach a description of the services and applicable CDT codes)

6.3 The state assures that, with respect to pre-existing medical conditions, one of the following two statements applies to its plan: (42CFR 457.480)

6.3.1.

The state shall not permit the imposition of any pre-existing medical condition exclusion for covered services (Section 2102(b)(1)(B)(ii)); OR 6.3.2.

The state contracts with a group health plan or group health insurance coverage, or contracts with a group health plan to provide family coverage under a waiver (see Section 6.4.2. of the template). Pre-existing medical conditions are permitted to the extent allowed by HIPAA/ERISA (Section 2103(f)). Please describe: Previously 8.6

6.4. Additional Purchase Options. If the state wishes to provide services under the plan through cost effective alternatives or the purchase of family coverage, it must request the appropriate option. To be approved, the state must address the following: (Section 2105(c)(2) and (3)) (42 CFR 457.1005 and 457.1010)

6.4.1.

Cost Effective Coverage. Payment may be made to a state in excess of the 10% limitation on use of funds for payments for: 1) other child health assistance for targeted low-income children; 2) expenditures for health services initiatives under the plan for improving the health of children (including targeted low-income children and other low-income children); 3) expenditures for outreach activities as provided in section 2102(c)(1) under the plan; and 4) other reasonable costs incurred by the state to administer the plan, if it demonstrates the following (42CFR 457.1005(a)): 6.4.1.1. Coverage provided to targeted low-income children through such expenditures must meet the coverage requirements above; Describe the coverage provided by the alternative delivery system. The state may cross reference section 6.2.1 - 6.2.28. (Section 2105(c)(2)(B)(i)) (42CFR 457.1005(b)) 6.4.1.2. The cost of such coverage must not be greater, on an average per child basis, than the cost of coverage that would otherwise be provided for the coverage described above; Describe the cost of such coverage on an average

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per child basis. (Section 2105(c)(2)(B)(ii)) (42CFR 457.1005(b)) 6.4.1.3. The coverage must be provided through the use of a community-based health delivery system, such as through contracts with health centers receiving funds under section 330 of the Public Health Service Act or with hospitals such as those that receive disproportionate share payment adjustments under section 1886(c)(5)(F) or 1923 of the Social Security Act. Describe the community-based delivery system. (Section 2105(c)(2)(B)(iii)) (42CFR 457.1005(a))

6.4.2.

Purchase of Family Coverage. Describe the plan to purchase family coverage. Payment may be made to a state for the purpose of family coverage under a group health plan or health insurance coverage that includes coverage of targeted low- income children, if it demonstrates the following: (Section 2105(c)(3)) (42CFR 457.1010)

6.4.2.1. Purchase of family coverage is cost-effective relative to the amounts that the state would have paid to obtain comparable coverage only of the targeted low-income children involved; and (Describe the associated costs for purchasing the family coverage relative to the coverage for the low income children.) (Section 2105(c)(3)(A)) (42CFR 457.1010(a)) 6.4.2.2. The state assures that the family coverage would not otherwise substitute for health insurance coverage that would be provided to such children but for the purchase of family coverage. (Section 2105(c)(3)(B)) (42CFR 457.1010(b)) 6.4.2.3. The state assures that the coverage for the family otherwise meets title XXI requirements. (42CFR 457.1010(c))

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Section 7. Quality and Appropriateness of Care

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state‟s Medicaid plan, and continue on to Section 8.

7.1. Describe the methods (including external and internal monitoring) used to assure the quality and appropriateness of care, particularly with respect to well-baby care, well-child care, and immunizations provided under the plan. (2102(a)(7)(A)) (42CFR 457.495(a))

Will the state utilize any of the following tools to assure quality? (Check all that apply and describe the activities for any categories utilized.) 7.1.1.

Quality standards

The Department of Human Services (DHS) encourages all contracted managed health plans to pursue National Committee for Quality Assurance (NCQA) or Joint Commission on Accreditation of Healthcare Organizations (JCAHO) certification. 7.1.2.

Performance measurement

Refer to Section 9.1 The hawk-i Functional Health Assessment Survey The report presents the results of an ongoing evaluation of the impact of the Healthy and Well Kids in Iowa (hawk-i) Program on the access to and health status of enrolled children. The first evaluation, parents‟ responses to a survey given at the time they joined the program (the baseline survey) are compared with their responses to a survey given after their child has been enrolled for about a year (the follow-up survey) to determine if there are differences in the perceived ability to receive health services or in their child‟s health status. Also included in the follow-up survey and presented in the report are questions specific to hawk-i, such as ratings to the private health plans that contact with hawk-i and the impact of having health insurance.

7.1.3.

Information strategies All health plans participating in the hawk-i program are required to provide encounter data in accordance with the provisions outlined in their contract.

Additionally, all health plans are required to provide written information to enrollees which, at a minimum, includes the following: the phone number(s) that can be used for assistance to

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obtain information about emergency care, prior authorization, scheduling appointments, and standard benefit/services information; current provider directory; hours of service of the plan; appeal procedures; policies on the use of emergency services; information on the sue of non-participating providers; access of after-hours care; enrollee rights and responsibilities; procedures for notifying enrollees of changes in the benefits or delivery of services; and procedures for recommending changes in policies and procedures.

7.1.4.

Quality improvement strategies All health plans participating in the hawk-i program are required to have quality improvement plans in place, including mechanisms that allow enrollees to provide input as to how the delivery of services and other aspects of the plan could be improved. The Clinical Advisory Committee meets quarterly to review data, reports and medical audit results. The committee makes recommendations to the hawk-i Board on program quality standards and improvement strategies. The nine-member committee is comprised of community medical professionals representing pediatricians, family practice, dental, mental health, nutrition and pharmacy.

7.2. Describe the methods used, including monitoring, to assure: (2102(a)(7)(B)) (42CFR 457.495)

7.2.1 Access to well-baby care, well-child care, well-adolescent care and childhood and adolescent immunizations. (Section 2102(a)(7)) (42CFR 457.495(a)) All health plans are contractually required to provide well-baby care and well-child care, well-adolescent care and childhood and adolescent immunization services. All participating health plans send reminder notices to families that their child(ren) is due for immunizations or well-child visits. Additionally, newsletters are sent to families educating them about the importance of preventative services.

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The hawk-i Program collects encounter claims data from participating health and dental plans monthly. HEDIS performance measurements for well-child and adolescent care have been selected for results based analysis (see 9.1). Effective July 1, 2005, the Department has a contract with Iowa Foundation for Medical Care to validate the encounter claims data with a medical record review. hawk-i„s Functional Health Assessment Survey is an excellent tool to evaluate health status of children enrolled in the hawk-i program.

7.2.2 Access to covered services, including emergency services as defined in 42 CFR 457.10. (Section 2102(a)(7)) 42CFR 457.495(b)) DHS examines access to care through the IFMC contract. Additionally, DHS uses Geographic Information Systems (GIS) maps to examine the distribution of primary care, dental, and mental health providers for each participating health plan at the county level of geography. The map tracks the geographical distribution of providers in comparison to the number of beneficiaries served in a particular coverage area as well as the distance and time to get to the provider. Access standards utilized for the GIS are 30 minutes/30 miles for primary care provider and dental services, 60 minutes/60 miles for specialty services including mental health and substance abuse. As noted above, health plans are contractually required to include written procedures in the member handbook on accessing emergency services. Contracted health and dental plans are required to submit complaint/grievance reports to the Department on a quarterly basis. Additionally, assessment surveys ask specific questions about the member‟s satisfaction with emergency services.

7.2.3 Appropriate and timely procedures to monitor and treat enrollees with chronic, complex, or serious medical conditions, including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of-network providers when the network is not adequate for the enrollee‟s medical condition. (Section 2102(a)(7)) (42CFR 457.495(c))

Contractually, health plans are required to ensure patient care that is coordinated and continuous, including at a minimum: systems to assure timely and appropriate referrals for Medically Necessary, specialty, secondary and tertiary care including subspecialization for pediatric care as well as health education services for members; and

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systems to assure provision of care in situations requiring treatment for an emergency medical condition, including an education process to help assure that members know where and how to obtain medically necessary care in an emergency. systems to assure that the plan shall not limit providers from disclosing all information about services available to the member related to their medical condition irrespective of the plans coverage or provider network. Iowa House File (HF2517), the bill that created the hawk-i program, mandated that a Special Needs Committee be established to make recommendations to the board and to the general assembly concerning the provision of health insurance coverage to children with special health care needs under the program. The purpose of the Committee is to address the following: 1) Define the target population of children with special health care needs for the purposes of determining eligibility under the program. 2) Eligibility options for and assessment of children with special health care needs for eligibility. 3) Benefit options for children with special health care needs. 4) The appropriateness and quality of care for children with special health care needs. 5) Coordination of health services provided for children with special health care needs under the program with services provided by other publicly funded programs. The Special Needs Committee has periodic meetings with contracted health plans to discuss case management services for members with long-term health care needs. The Functional Health Assessment Survey asks questions related specifically to a child with chronic medical conditions (see 7.1.2).

7.2.4 Decisions related to the prior authorization of health services are completed in accordance with state law or, in accordance with the medical needs of the patient, within 14 days after the receipt of a request for services. (Section 2102(a)(7)) (42CFR 457.495(d))

The following language is included in all health plan contracts follows: “If the Plan has Prior Authorization of health services, in accordance with the medical needs of the patient, the Plan shall complete the Prior authorization within fourteen (14) days after receipt of a request for services. An extension of up to fourteen (14) days may be permitted if the Enrollee requests the extension or if the physician or Plan determines that additional information is needed.“

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Section 8. Cost Sharing and Payment (Section 2103(e))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state‟s Medicaid plan, and continue on to Section 9.

8.1. Is cost-sharing imposed on any of the children covered under the plan? (42CFR 457.505) 8.1.1.

YES 8.1.2.

NO, skip to question 8.8.

8.2. Describe the amount of cost-sharing, any sliding scale based on income, the group or groups of enrollees that may be subject to the charge and the service for which the charge is imposed or time period for the charge, as appropriate. (Section 2103(e)(1)(A)) (42CFR 457.505(a), 457.510(b) &(c), 457.515(a)&(c)) 8.2.1. Premiums: For enrollees with countable income exceeding 200 percent but not exceeding 300 percent of the FPL, premiums will be $20 per month per child with a monthly family maximum of $40. For enrollees with countable income equal to or exceeding 150 percent but not exceeding 200 percent of FPL, premiums will be $10 per month per child, with a monthly family maximum of $20. For enrollees with countable earned and unearned income less than 150% of the FPL, no premium is assessed. No cost-sharing is assessed for eligible Native American / Alaskan Native children regardless of family income. If a family reports a decrease in income anytime during the 12-month eligibility period and the new income is less than 150% of the FPL, the family does not pay a premium for the reminder of the eligibility period. For the months of June 2008 and July 2008, the premiums for families with countable income that equals or exceeds 150% of FPL are waived. The basis for this waiver is good cause due to the financial hardship for those families with limited income in any of the Iowa counties that have been declared a disaster by the Governor of Iowa and/or Presidential Declaration of Disaster for Individual Assistance. See Attachment 14 for the list of Iowa counties affected as of June 30, 2008. 8.2.2. Deductibles: None 8.2.3. Coinsurance or copayments: Families whose countable income is equal to or greater than 150% of the FPL shall be assessed a $25 copayment for each emergency room visit if the child's medical condition does not meet the definition of

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emergency medical condition. Copayments are not assessed for Native American, Alaskan Native children, regardless of income. An emergency medical condition means a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a prudent lay person, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in one of the following: 1. Placing the health of the person or, with respect to a pregnant woman, the health of the woman and her unborn child, in serious jeopardy, 2. Serious impairment to bodily functions or, 3. Serious dysfunction of any bodily organ or part.

8.2.4. Other:

8.2- DS For children enrolled in the dental-only supplemental coverage, please describe the amount of cost-sharing, specifying any sliding scale based on income. Please also describe how the State will track that the cost sharing does not exceed 5 percent of gross family income. The 5 percent of income calculation shall include all cost-sharing for health insurance and dental insurance (Section 2103(e)(1)(A)) (42 CFR 457.505(a), 457.510(b), and (c), 457.515(a) and (c), and 457.560(a))

8.2.1.-D Premiums: Premiums for participation in the dental-only supplemental program are assessed as follows: a. No premium is charged to families whose countable income is less than 150 percent of the FPL. b. If the family‟s countable is equal to or exceeds 150 percent of FPL, but does not exceed 200 percent of the FPL for a family of the same size, the premium is $5 per child per month with a $10 monthly maximum per family. c. If the family‟s countable income exceeds 200 percent of the FPL, but does not exceed 250 percent of the FPL for a family of the same size, the premium is $10 per child per month with a $15 monthly maximum per family. d. If the family‟s countable income exceeds 250 percent of the FPL, but does not exceed 300 percent of the FPL for a family of the same size, the premium is $15 per child per month with a $20 monthly maximum per family. For families that include uninsured children who are eligible for both health and dental coverage under hawk-i and insured children who

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are eligible only for dental coverage, the premium shall be assessed as follows: a. The total premium shall be no more than what the family would pay if all the children were eligible for both health and dental coverage. b. If the family has one child eligible for both health and dental coverage and one child eligible for dental-only supplemental coverage only, the premium shall be the total of the health and dental premium for one child and the dental premium for one child. c. If the family has two or more children eligible for both health and dental coverage, no additional premium shall be assessed for dental-only supplemental coverage for the children who do not qualify for health coverage under hawk-i because they are insured. 8.2.2.-D Deductibles: There are no deductibles for the dental-only supplemental coverage. 8.2.3.-D Coinsurances or copayments: There are no coinsurances or copayments for the dental-only supplemental coverage. 8.2.4.-D Other: No cost-sharing is assessed for eligible Native American / Alaskan Native children regardless of family income. The maximum total cost-sharing for a family may have is $40 per month or $240 per 12-month enrollment period. See response to 8.5 below regarding the 5 percent income limit for cost sharing.

8.3. Describe how the public will be notified, including the public schedule, of this cost sharing (including the cumulative maximum) and changes to these amounts and any differences based on income. (Section 2103(e)((1)(B)) (42CFR 457.505(b)) Cost sharing is described in the Iowa Administrative Rules and in printed materials about the program, including the informational brochure that contains the application form. (See Attachment 7) Additionally, when approved, each family will receive an approval notice that lists their countable income calculation and the amount of cost sharing, if any.

8.4. The state assures that it has made the following findings with respect to the cost sharing in its plan: (Section 2103(e)) 8.4.1.

Cost-sharing does not favor children from higher income families over lower income families. (Section 2103(e)(1)(B)) (42CFR 457.530)

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8.4.2.

No cost-sharing applies to well-baby and well-child care, including age-appropriate immunizations. (Section 2103(e)(2)) (42CFR 457.520) 8.4.3

No additional cost-sharing applies to the costs of emergency medical services delivered outside the network. (Section 2103(e)(1)(A)) (42CFR 457.515(f)) 8.5. Describe how the state will ensure that the annual aggregate cost-sharing for a family does not exceed 5 percent of such family‟s income for the length of the child‟s eligibility period in the State. Include a description of the procedures that do not primarily rely on a refund given by the state for overpayment by an enrollee: (Section 2103(e)(3)(B)) (42CFR 457.560(b) and 457.505(e)) There are only two forms of cost sharing in the hawk-i program, premiums and a copayment for treatment in an emergency room for a non-emergent medical condition. In both cases, they apply only to families with income that equals or exceed 150% of FPL. A. Premiums There are three premium tiers based on family income and the benefits received. a. Premiums for full coverage (medical and dental) in the hawk-i program are: i. For enrollees with countable income exceeding 200 percent but not exceeding 300 percent of the FPL, premiums will be $20 per month per child with a monthly family maximum of $40. ii. For enrollees with countable income equal to or exceeding 150 percent but not exceeding 200 percent of FPL, premiums will be $10 per month per child, with a monthly family maximum of $20. b. Premiums for dental-only supplemental coverage are: i. If the family‟s countable income equals or exceeds 150% of the FPL, but does not exceed 200 percent of the FPL for a family of the same size; the premium is $5 per child per month with a $10 monthly maximum per family. ii. If the family‟s countable income exceeds 200 percent of the FPL, but does not exceed 250 percent of the FPL for a family of the same size, the premium is $10 per child per month with a $15 monthly maximum per family. iii. If the family‟s countable income exceeds 250 percent of the FPL, but does not exceed 300 percent of the FPL for a family of the

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same size, the premium is $15 per child per month with a $20 monthly maximum per family. Since the premiums are the only cost sharing incurred by the family, the annual cost sharing will not exceed 5% of the family‟s income. See response in 8.2.4 D. c. Premiums for families that include children who are eligible for both health and dental coverage under hawk-i and insured children who are eligible only for dental coverage are: i. The total premium shall be no more than what the family would pay if all the children were eligible for both health and dental coverage. ii. If the family has one child eligible for both health and dental coverage and one child eligible for dental-only supplemental coverage, the premium shall be the total of the health and dental premium for one child and the dental premium for one child. iii. If the family has two or more children eligible for both health and dental coverage, no additional premium shall be assessed for dental-only supplemental coverage for the children who do not qualify for health coverage because they are insured. B. Emergency copayment: For families that have health care coverage and their income is equal or exceeds 150% of the FPL, a copayment of $25.00 applies for inappropriate use of the emergency room. At current poverty levels, the family that pays premiums would have to incur the number of inappropriate emergency room visits indicated below to exceed 5%. Health plans will report enrollee ER usage, resulting in a copayment obligation, to the third party administrator. The third party administrator will track the ER copayment to ensure cost sharing does not exceed 5% of the family income. At the point the ER copayment results in cost sharing exceeding 5%, enrollees will be reimbursed for the cost. It is expected that the health plans will intervene to educate enrollees about the appropriate use of ER services prior to any family utilizing the ER inappropriately in as many instances indicated in the chart.

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No. of children in family Annual Income at 300% FPL 5% Premium Maximum 5% minus premium maximum No. of Annual Inappropriate ER Visits 1 $32,490 $1,624.50 $240 $1,384.50 ($1384.50/$25) 55 2 $43,710 $2,185.50 $480 $1,705.50 ($1705.50/$25) 68 3 $54,930 $2,746.50 $480 $2,266.50 ($2266.50/$25) 91 4 $66,150 $3,307.50 $480 $2,827.50 ($2827.50/$25) 113 5 $77,370 $3,868.50 $480 $3,388.50 ($3388.50/$25) 136 6 $88,590 $4,429.50 $480 $3,949.50 ($3949.50/$25) 158 7 $99,810 $4,990.50 $480 $4,510.50 ($4510.50/$25) 180 8 $111,030 $5,551.50 $480 $5,071.50 ($5071.50/$25) 203

No cost-sharing is assessed for eligible Native American / Alaskan Native children regardless of family income for both the hawk-i program and the dental only program. 8.6. Describe the procedures the state will use to ensure American Indian (as defined by the Indian Health Care Improvement Act of 1976) and Alaska Native children will be excluded from cost-sharing. (Section 2103(b)(3)(D)) (42CFR 457.535)

The brochure that contains the hawk-i application states that there is no cost sharing for American Indian/Alaskan Native children. At the time the applicant is approved for the hawk-i program, an approval notice is sent indicating there is no cost sharing. These provisions are also found in the Iowa Administrative Code at 441- 86.8(1). Applications to the hawk-i program ask for the race of the children applying. When race is indicated as Native American or Alaska Native, no cost sharing is assessed to American Indian or Alaska Native children, regardless of income.

8.7. Please provide a description of the consequences for an enrollee or applicant who does not pay a charge. (42CFR 457.570 and 457.505(c))

Premiums are due by the 5th day (or the next business day, if the 5th falls on a holiday or weekend) of the month prior to the coverage month. If the premium has not been received by the 5th or the next business day, if the 5th falls on a holiday or weekend, a reminder notice is sent. All notices of adverse action contain appeal rights language on the reverse side. The following example illustrates the actions associated with the premium for the coverage month of November.

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Date Action Length of Time September 21st Invoice for November is sent

October 5th November premium is due 13 days from when the original invoice is sent. October 6th Reminder notice is sent if November premium is not received by October 5th 14th day from when the original invoice is sent. October 21st Invoice for November and December premiums due is sent This is the second invoice for the November premium, which is 17 days after the premium due date. November 5th Notice of cancellation is sent for November premium and reminder notice sent for December premium if it is not received by November 5th. This notice is sent 30 days after the November premium is due. Coverage for November continues. November 8th Notice of cancellation for November 30th is sent if the November premium was not received. This is 33 days after the November due date. November 30th If the November premium has not been paid on or before November 30th, disenrollment occurs and there is no coverage beginning December 1st. This is 56 days after the November premium due date.

Initial Application: When an approval decision has been made on an initial application, the first premium due is for the third month of the twelve-month enrollment period. Example: A child is approved on October 15th with an effective date of November 1st. The first premium is due on December 5th for the month of January.

Renewal Application: When an approval decision has been made on a renewal application, the first premium due is the first month of the new twelve- month enrollment period. Example: The initial enrollment period ends November 30th. The renewal application is received in September and approved in September for a new enrollment period. The first premium due is October 5th for November (the first month of the enrollment period).

If a family reports a decrease in income and a premium is no longer required, premiums will no longer be charged beginning with the month following the

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month of the report of the change. Any time an adverse action is taken such as disenrollment and cancellation from the program, the enrollee has the right to appeal the decision. The appeal rights and procedures are written on the backside of the notice. If the premium is not received by the tenth working day, the applicant is sent a notice of denial of eligibility. The applicant has the right to appeal this decision. The state is using the Statewide Standard Review. Section 514I.2(10) of the Iowa Code requires all participating health plans to be licensed by the Iowa Division of Insurance. All hawk-i enrollees receive services from health insurance issuers subject to state health insurance law. Managed care organizations are subject to Iowa Code Chapter 514B and indemnity health insurance carriers are subject to Iowa Code Chapters 505, 514. All health services are subject to an external review as described in Iowa Code Chapter 514J. See Attachment 10.

8.7.1 Please provide an assurance that the following disenrollment protections are being applied:

State has established a process that gives enrollees reasonable notice of and an opportunity to pay past due premiums, copayments, coinsurance, deductibles or similar fees prior to disenrollment. (42CFR 457.570(a))

The disenrollment process affords the enrollee an opportunity to show that the enrollee‟s family income has declined prior to disenrollment for non-payment of cost-sharing charges. (42CFR 457.570(b))

In the instance mentioned above, that the state will facilitate enrolling the child in Medicaid or adjust the child‟s cost-sharing category as appropriate. (42CFR 457.570(b))

The state provides the enrollee with an opportunity for an impartial review to address disenrollment from the program. (42CFR 457.570(c))

8.8. The state assures that it has made the following findings with respect to the payment aspects of its plan: (Section 2103(e)) 8.8.1.

No Federal funds will be used toward state matching requirements. (Section 2105(c)(4)) (42CFR 457.220) 8.8.2.

No cost-sharing (including premiums, deductibles, copays, coinsurance and all other types) will be used toward state matching requirements. (Section 2105(c)(5) (42CFR 457.224) (Previously 8.4.5)

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8.8.3.

No funds under this title will be used for coverage if a private insurer would have been obligated to provide such assistance except for a provision limiting this obligation because the child is eligible under the this title. (Section 2105(c)(6)(A)) (42CFR 457.626(a)(1)) 8.8.4.

Income and resource standards and methodologies for determining Medicaid eligibility are not more restrictive than those applied as of June 1, 1997. (Section 2105(d)(1)) (42CFR 457.622(b)(5)) 8.8.5.

No funds provided under this title or coverage funded by this title will include coverage of abortion except if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest. (Section 2105)(c)(7)(B)) (42CFR 457.475) 8.8.6.

No funds provided under this title will be used to pay for any abortion or to assist in the purchase, in whole or in part, for coverage that includes abortion (except as described above). (Section 2105)(c)(7)(A)) (42CFR 457.475)

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Section 9. Strategic Objectives and Performance Goals and Plan Administration (Section 2107)

9.1. Describe strategic objectives for increasing the extent of creditable health coverage among targeted low-income children and other low-income children: (Section 2107(a)(2)) (42CFR 457.710(b))

Objective Two: Increase the number of children who have access to health care. Objective Three: Appropriate use of medications for children diagnosed with asthma. Objective Four: Children participating in the Medicaid Expansion and hawk-i will have access to primary care practitioners.

9.2. Specify one or more performance goals for each strategic objective identified: (Section 2107(a)(3)) (42CFR 457.710(c))

Objective One: Increase the health status of children in Iowa. Medicaid Expansion (M-CHIP) health status goals: Health status and health care system measures will show acceptable incremental improvements for the following outcome measurements: Healthy and Well Kids in Iowa (hawk-i) (S-CHIP): Health status and health care system measures will show acceptable incremental improvements for the following outcome measurements: 1. Fifty percent of the children ages zero to 15 months enrolled in the hawk-i program will have at least one well-child visit. 2. Eighty percent of the children ages three, four, five and six years old enrolled in the hawk-i program will have well-child visits. 3. Send each family a health assessment questionnaire to complete for one child in the household. (Refer to Attachment 8).

Objective Two: Increase the number of children who have access to health care. Medicaid Expansion (M-CHIP) Enroll approximately 17,300 total children in the Medicaid

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expansion program. hawk-i Program (S-CHIP) Enroll approximately 31,300 children into health plans participating in the hawk-i program.

Objective Three: Appropriate use of medications for children diagnosed with asthma. Medicaid Expansion (M-CHIP) Sixty-five percent of children enrolled in the Medicaid Expansion program that have a diagnosis of asthma will have long-term control medications. hawk-i (S-CHIP) Fifty percent of the children enrolled in the hawk-i program that have a diagnosis of asthma will have long-term control medications.

Objective Four: Medicaid Expansion (M-CHIP) Eighty-five percent of the children enrolled in the Medicaid expansion program will have access to a primary care practitioner. hawk-i (S-CHIP) Eighty-five percent of the children enrolled in the hawk-i program will have access to a primary care practitioner.

9.3. Describe how performance under the plan will be measured through objective, independently verifiable means and compared against performance goals in order to determine the state‟s performance, taking into account suggested performance indicators as specified below or other indicators the state develops: (Section 2107(a)(4)(A),(B)) (42CFR 457.710(d))

Assurance of an Objective Means for Measuring Performance Iowa will measure performance by establishing a baseline for each performance goal through various methods including: conducting a baseline population-based survey; using State vital records, hospital discharge and claims information; and using other Medicaid and non-Medicaid databases that provide relevant information. For each performance goal, the method of measurement will be established and reports will be generated to monitor, on an ongoing basis, Iowa's progress toward meeting the goal.

Objective One: Increase the health status of children in Iowa.

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Measurement of Performance: Every family approved for the hawk-i program will be asked to complete a health assessment questionnaire for one child in the household. (Refer to Attachment 8). The State has contracted with the Iowa Foundation for Medical Care to analyze the results of the survey, both at the initial submission and the next review (12 months) when the family is asked to complete the survey on their past 12 month's experience. Survey outcomes for hawk-i include: 1) Access to care (unmet need) and regular source of medical care, 2) ER use, 3) Unmet need and regular source of dental care, 4) Unmet need for vision care, pharmacy, and behavioral/emotional care, 5) Receipt of anticipatory guidance 6) Child‟s health status 7) Family environment (e.g., stress) Well-child visits in the third, fourth, fifth and sixth years of life will be measured using HEDIS measurements for both the Medicaid Expansion (M-CHIP) and hawk-i (S- CHIP) programs.

Objective Two: Increase the number of children who have access to health care. Measurement of Performance: Enrollment for the Medicaid expansion and the hawk-i programs will be measured using monthly enrollment reports.

Objective Three: Appropriate use of medications for children diagnosed with asthma. Measurement of Performance Medicaid Expansion (M-CHIP) HEDIS measurement set relevant to children and adolescents younger than 21 without modifications. hawk-i Program (S-CHIP) HEDIS measurement set relevant to children and adolescents younger than 19 with modifications.

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Objective Four: Children participating in the Medicaid Expansion (M-CHIP) and hawk-i (S-CHIP) programs will have access to primary care practitioners. Measurement of Performance HEDIS measurements with modifications for both the Medicaid Expansion (M-CHIP) and the hawk-i (S-CHIP) programs.

Check the applicable suggested performance measurements listed below that the state plans to use: (Section 2107(a)(4)) 9.3.1.

The increase in the percentage of Medicaid-eligible children enrolled in Medicaid. 9.3.2.

The reduction in the percentage of uninsured children. 9.3.3.

The increase in the percentage of children with a usual source of care. 9.3.4.

The extent to which outcome measures show progress on one or more of the health problems identified by the state. 9.3.5.

HEDIS Measurement Set relevant to children and adolescents younger than 19. 9.3.6.

Other child appropriate measurement set. List or describe the set used. 9.3.7.

If not utilizing the entire HEDIS Measurement Set, specify which measures will be collected, such as: 9.3.7.1. Immunizations 9.3.7.2. Well childcare 9.3.7.3. Adolescent well visits 9.3.7.4. Satisfaction with care 9.3.7.5. Mental health 9.3.7.6. Dental care 9.3.7.7. Other, please list: 9.3.8.

Performance measures for special targeted populations.

9.4.

The state assures it will collect all data, maintain records and furnish reports to the Secretary at the times and in the standardized format that the Secretary requires. (Section 2107(b)(1)) (42CFR 457.720)

9.5.

The state assures it will comply with the annual assessment and evaluation required under Section 10. Briefly describe the state‟s plan for these annual assessments and reports. (Section 2107(b)(2)) (42CFR 457.750)

Iowa‟s SCHIP annual report is completed by January 1 following the end of the Federal fiscal year utilizing the framework template

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developed by the National Academy for State Health Policy (NASHP). The March supplement to the Current Population Survey (CPS) is utilized to calculate the baseline number of uncovered low-in children in Iowa. The State has an approved Section 1915(b) waiver for Primary Care Case Management (PCCM). The State is responsible for assessment and evaluation under the PCCM waiver and intends to use the same investigator and contract for his Medicaid Expansion as used for the PCCM. The investigator (the Public Policy Center at the University of Iowa) will have access to Medicaid data and can develop measures such as number of office visits, continuity of care, and hospitalizations that would compare the newly enrolled group to the currently existing Medicaid population.

9.6.

The state assures it will provide the Secretary with access to any records or information relating to the plan for purposes of review of audit. (Section 2107(b)(3)) (42CFR 457.720)

9.7.

The state assures that, in developing performance measures, it will modify those measures to meet national requirements when such requirements are developed. (42CFR 457.710(e))

9.8. The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42CFR 457.135)

9.8.1.

Section 1902(a)(4)(C) (relating to conflict of interest standards) 9.8.2.

Paragraphs (2), (16) and (17) of Section 1903(i) (relating to limitations on payment) 9.8.3.

Section 1903(w) (relating to limitations on provider donations and taxes) 9.8.4.

Section 1132 (relating to periods within which claims must be filed)

9.9. Describe the process used by the state to accomplish involvement of the public in the design and implementation of the plan and the method for insuring ongoing public involvement. (Section 2107(c)) (42CFR 457.120(a) and (b))

The initial implementation of hawk-i included public involvement through an appointed task force, public forums and the creation of the hawk-i Board (see 1.3). Rural and urban focus groups were also held to obtain input into the

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application and outreach materials. There are two venues by which the public can provide input into any changes made in the hawk-i program: 1) The hawk-i Board meetings are held monthly and are open to the public. The agenda for the Board meeting is posted on the hawk-i website prior to the meeting. During each meeting time is allowed for public comment on any changes being proposed or any aspect of the program; or 2) Through the administrative rules process. The Administrative Procedures Act, Iowa Code Chapter 17A, requires all state agencies to promulgate rules for the operation of their programs. The rule-making process increases agencies‟ accountability to the public, allows public participation in the formulation of rules, and provides legislative oversight for program operations. Before the Department‟s rules are adopted, they are published in the Iowa Administrative Bulletin as a "notice of intended action." Any interested people may submit comments on the proposed rules within time frames set forth in the notice. All notices must allow at least 20 days for persons to submit comments or to request an oral presentation. The Department may not adopt the rules until 35 days after the date the notice of intended action is published. Following notice and adoption, the final rules are again published in the Iowa Administrative Bulletin. They become effective at a date specified with the final rule. Normally the Department must allow at least 35 days from the date of publication for people to prepare to implement the rules. The hawk-i Board first approves any proposed changes to the hawk-i administrative rules during public meetings. The rules then go through the Department's administrative rules process. The hawk-i Board must then approve the rules for a second time during a public meeting before they are adopted.

9.9.1 Describe the process used by the state to ensure interaction with Indian Tribes and organizations in the state on the development and implementation of the procedures required in 42 CFR 457.125. (Section 2107(c)) (42CFR 457.120(c))

In addition to sending the proposed changes to our Administrative Rules to the tribes, the proposed rule changes are published in the Administrative Bulletin and are brought before the hawk-i Board meeting twice, one for noticing and once for adoption. Meetings of the hawk-i Board are open to the public and minutes of the meetings are posted on the hawk-i website for public access. Also, information on

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any programmatic changes to the hawk-i program is presented to the grassroots outreach coordinators who are required to work specifically with any tribes in their areas.

9.9.2 For an amendment relating to eligibility or benefits (including cost sharing and enrollment procedures), please describe how and when prior public notice was provided as required in §457.65(b) through (d). See the response for 9.9.

9.10. Provide a one year projected budget. A suggested financial form for the budget is attached. The budget must describe: (Section 2107(d)) (42CFR 457.140)

Planned use of funds, including -- Projected amount to be spent on health services; Projected amount to be spent on administrative costs, such as outreach, child health initiatives, and evaluation; and Assumptions on which the budget is based, including cost per child and expected enrollment. Projected sources of non-Federal plan expenditures, including any requirements for cost-sharing by enrollees.

9.10.1-DS Please include a separate budget line to indicate the cost of providing dental-only supplemental coverage.

SCHIP Budget Plan FFY 10 IOWA - for supplemental dental

Federal Fiscal Year Costs Enhanced FMAP rate 74.46% Benefit Costs

Population 1 - hawk-i - Iowa's stand alone program

Insurance payments $0 Managed care $62,228,537 per member/per month rate @ # of eligibles $194 Fee for Service $0 per member/per month rate @ # of eligibles n/a Benefit Costs subtotal population 1 $62,228,537 Population 2 - Supplemental Dental

Insurance payments $3,170,827 per member/per month rate @ # of eligibles $26 Benefit Costs subtotal population 2 $3,170,827

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SCHIP Budget Plan FFY 10 IOWA - for supplemental dental Population 3 - expanded Medicaid

Managed care $0 per member/per month rate @ # of eligibles n/a Fee for Service $31,076,850 per member/per month rate @ # of eligibles $173 Benefit Costs subtotal popuation 3 $31,076,850 Population 4 LPRs

43 children added over a 18 month period

hawk- i (28 children added over an 18 month period) $9,079 Expanded Medicaid (15 children added over an 18 month period) $4,889 Benefit costs subtotal Population 4 $13,968 Total Benefit Costs $96,490,182 (Offsetting beneficiary cost sharing payments) -$2,036,930 Net Benefit Costs $94,453,252 Administration Costs

Personnel $459,188 General administration $518,781 Contractors/Brokers (e.g., enrollment contractors) $4,042,002 Claims Processing $2,077,540 Outreach/marketing costs $1,243,970 Other (cost allocation) $920,000 Total Administration Costs $9,261,481 10% Administrative Cost Ceiling $10,494,806

Federal Share (multiplied by enh-FMAP rate) $77,225,990 State Share $26,488,743 TOTAL PROGRAM COSTS $103,714,733 NOTE 1: The Federal Fiscal Year (FFY) runs from October 1st through September 30th. 2. What were the sources of non-Federal funding used for State match during the reporting period? XX State appropriations

County/local funds

Employer contributions

Foundation grants

Private donations

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SCHIP Budget Plan FFY 10 IOWA - for supplemental dental

Tobacco settlement

Other (specify) [500] 4. In the table below, enter 1) number of eligibles used to determine per member per month costs for the current year; and, 2) per member per month cost rounded to a whole number. If you have SCHIP enrollees in a fee for service program, per member per month cost will be the average cost per month to provide services to these enrollees.

2010 # of eligibles $ PMPM Insurance payments -

$ - Managed Care 28,170 $ 194 Fee for Service 14,989 $ 173 Supplemental dental insurance payments 6,440 $ 26

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Section 10. Annual Reports and Evaluations (Section 2108)

10.1. Annual Reports. The state assures that it will assess the operation of the state plan under this Title in each fiscal year, including: (Section 2108(a)(1),(2)) (42CFR 457.750)

10.1.1.

The progress made in reducing the number of uncovered low- income children and report to the Secretary by January 1 following the end of the fiscal year on the result of the assessment, and

10.2.

The state assures it will comply with future reporting requirements as they are developed. (42CFR 457.710(e))

10.3.

The state assures that it will comply with all applicable Federal laws and regulations, including but not limited to Federal grant requirements and Federal reporting requirements.

10.3-D Specify that the State agrees to submit yearly the approved dental benefit package and to submit quarterly the required information on dental providers in the State to the Health Resources and Services Administration for posting on the Insure Kids Now! Website.

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Section 11. Program Integrity (Section 2101(a))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state‟s Medicaid plan, and continue to Section 12.

11.1.

The state assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Section 2101(a)) (42CFR 457.940(b))

11.2. The state assures, to the extent they apply, that the following provisions of the Social Security Act will apply under Title XXI, to the same extent they apply to a state under Title XIX: (Section 2107(e)) (42CFR 457.935(b)) The items below were moved from section 9.8. (Previously items 9.8.6. - 9.8.9) 11.2.1.

42 CFR Part 455 Subpart B (relating to disclosure of information by providers and fiscal agents) 11.2.2.

Section 1124 (relating to disclosure of ownership and related information) 11.2.3.

Section 1126 (relating to disclosure of information about certain convicted individuals) 11.2.4.

Section 1128A (relating to civil monetary penalties) 11.2.5.

Section 1128B (relating to criminal penalties for certain additional charges) 11.2.6.

Section 1128E (relating to the National health care fraud and abuse data collection program)

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Section 12. Applicant and Enrollee Protections (Sections 2101(a))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state‟s Medicaid plan.

12.1. Eligibility and Enrollment Matters with 42 CFR 457.1120.

The Iowa Department of Human Services uses the same appeal process for all of its programs, including Medicaid and hawk-i eligibility and enrollment. This process is detailed in Attachment 9.

12.2. Health Services Matters

Please describe the review process for health services matters that comply with 42 CFR 457.1120.

The state is using the Statewide Standard Review. Section 514I.2(10) of the Iowa Code requires all participating health plans to be licensed by the Iowa Division of Insurance. All hawk-i enrollees receive services from health insurance issuers subject to state health insurance law. Managed care organizations are subject to Iowa Code Chapter 514B and indemnity health insurance carriers are subject to Iowa Code Chapters 505, 514. All health services are subject to an external review as described in Iowa Code Chapter 514J. See Attachment 10.

12.3. Premium Assistance Programs If providing coverage through a group health plan that does not meet the requirements of 42 CFR 457.1120, please describe how the state will assure that applicants and enrollees have the option to obtain health benefits coverage other than through the group health plan at initial enrollment and at each redetermination of eligibility.

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Attachment 2 Referral Process Enrollment Process for hawk-i Application is received by the Third Party Administrator (TPA)

Steps Yes No Unknown 1. Is the application signed? Application is date stamped, logged into the TPA‟s system and screened for Medicaid eligibility within 24 hours of receipt. Return application for signature within 24 hours.

2. Does Medicaid eligibility appear to exist? Send referral to co-located Income Maintenance Workers (IMW) for Medicaid eligibility determination using Medicaid policies and procedures. Determine eligibility for hawk-i within 10 working days of receiving a complete application. If hawk-i eligibility does not exist then deny application. If hawk-i eligibility does exist then notify family of plan choices and cost sharing obligation if applicable. Insufficient information to make determination. Request additional information. If requested information is not received timely, deny application. If requested information is received then determine if Medicaid eligibility exists and follow Yes and NO section of step 2. 3. Are the children eligible for Medicaid? Children are enrolled in Medicaid. Go to Step. 4. If no action has been taken on the application within 30 days, the TPA will follow-up with the co- located IMW for status. 4. Was the application denied because of failure to cooperate with Medicaid? Deny application for hawk-i coverage. Go to Step. 5

5. Was the application over income for Medicaid? Determine eligibility for hawk-i within 10 working days of receiving the Medicaid decision. if hawk-i eligibility does exist then notify family of plan choices and cost sharing if applicable. if hawk-i eligibility does not exist, deny application.

Referral Process from DHS to hawk-i

When Medicaid Application is Denied 1. Family applies for Medicaid at DHS office 2. The application is denied due to excess income.

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3. DHS completes an electronic or paper referral and sends the referral to hawk-i. (This occurs even if the Income Maintenance Worker is simultaneously determining Medically Needy eligibility with a spenddown.

When there is an existing Medicaid case at the DHS office 1. An ongoing Medicaid case is canceled due to excess income. 2. DHS completes an electronic or paper referral and sends the referral to hawk-i. (This occurs even if the Income Maintenance Worker is simultaneously determining Medically Needy eligibility with a spenddown.

For both situations, the TPA: 1. Logs the referral into the TPA system. 2. Proceeds with the hawk-i eligibility determination.

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Iowa Department of Human Services REFERRAL TO THE hawk-i PROGRAM Denied Application/Individual (provide Medicaid application date) Canceled Case/Individual Date: Case Name: Worker Name: Worker Number: Case Number: Worker County: Worker Phone: Case Phone: County of Residence: People in Household Social Security Number Birth Date Sex Citizen (If No, explain alien status in Comments) How Related to Case Name (spouse, parent, child, etc.) Medicaid End Date (only on canceled cases or individuals) Language Preference If child, do they have health insurance coverage? 1.

M F Yes No

English Spanish Other: Yes No 2.

M F Yes No

English Spanish Other: Yes No 3.

M F Yes No

English Spanish Other: Yes No 4.

M F Yes No

English Spanish Other: Yes No 5.

M F Yes No

English Spanish Other: Yes No 6.

M F Yes No

English Spanish Other: Yes No 7.

M F Yes No

English Spanish Other: Yes No

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This case is being referred to hawk-i because: The children must meet a spenddown under the Medically Needy program. The following children have been voluntarily excluded from the Medicaid eligible group because the child’s income creates Medicaid ineligibility for the remaining household members. Indicate the income of the voluntarily excluded child below in the next section. Also, attach an NOD showing the Medicaid eligibility calculation for the other family members. (Note: Children voluntarily excluded for non-financial reasons are not eligible for hawk-i.)

1.

2.

3.

4.

Income

Family members are employed at the following companies:

Family members have unearned income from the following sources: This case has (check all that apply):

Non-recurring lump sum Income:

Income of voluntarily excluded child: Amount prorated monthly (Standard of Need): $ $ per Last month and year of period of proration:

(week, month, etc)

(MM/YYYY) Income has been verified (attach verification to referral)

Self-employment income: Income has not been verified Amount of depreciation (from Schedule C or $ Comments

(or attach a copy of Schedule C or F)

Unemployment benefits: Name of person(s) receiving UIB: Attachments: Copy of Notice of Decision showing Medicaid ineligibility (Required) REMINDER – Only Refer Children Who Are Over Income For Medicaid Do Not Refer Children to the hawk-i Program Who: Are age 19 or older; or Are ineligible for Medicaid due to a non-cooperation issue. Send via local mail to: Department of Human Services Attn: MAXIMUS/hawk-i Program Division of Financial, Health and Work Supports 1305 E. Walnut Des Moines, IA 50319-0114 OR Fax: 515-457-7701

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hawk-i Referral Process A Desk Guide for Income Maintenance Workers Policy: Refer children under age 19 to the hawk-i program when any child for whom a family is applying is over income for Medicaid or is conditionally eligible for MN. (Employees‟ Manual Chapters 8-B & 8-G) Making a Referral: Referring a Denied Application Referring a Cancelled Case

To refer an application that has been denied or an application that has been approved only for MN with a spenddown:  Fill out the referral form* and send it to hawk-i with copies of: 1. the Medicaid application 2. the income verification 3. the notice of decision  Make the referral within one working day from the time that you know that the child is not eligible for Medicaid or that they must meet a spenddown under Medically Needy.  The Medicaid application date will become the hawk-i filing date. To refer a case that has been cancelled or must now meet a spenddown under MN:  Fill out the referral form* and send it to hawk-i with copies of: 1. the income verification 2. the notice of decision  Make the referral within one working day from the time that you know that the child is not eligible for Medicaid or that they must meet a spenddown under Medically Needy.  If eligible, there will be no break in coverage for children moving from Medicaid to hawk-i. The family does not have to fill out a separate hawk-i application. * “Referral to the Healthy and Well Kids in Iowa (hawk-i) Program,” form 470-3565, is available in State Approved Forms on Outlook.

Send the referral and accompanying verification to: (Do not send case records or original application forms)

Interoffice Mail: Department of Human Services OR FAX: 515-457-7701

Attn: MAXIMUS/hawk-i Program

IME

100 Army Post Road

Des Moines, IA 50315 Questions? Call hawk-i Customer Service: 1-800-257-8563 OVER

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Helpful Hints:

If a case goes over income because of a lump sum period of proration, but the children would otherwise be Medicaid eligible, note in the comments section of the referral form that there is a lump sum, how much it is, and when the period of proration ends.

If a child is voluntarily excluded from Medicaid because of the child‟s income, refer the child to hawk-i. Note in the upper right corner of the back page of the referral that the child is excluded and include their income information.

Do not refer children to hawk-i if the child has been voluntarily excluded from Medicaid for reasons other than the child‟s income.

Do not refer children to hawk-i when the reason they are not eligible for Medicaid is due to non-cooperation (e.g. failure to return review forms, failure to provide verification, etc.).

Self-employment: hawk-i allows a deduction for depreciation of capital assets for self- employment while Medicaid does not. In this situation, include the appropriate Schedule C or F when making the referral.

Unemployment: Medicaid looks at unemployment as a weekly benefit. hawk-i looks at the maximum benefit the person can receive and uses it to project income for the 12- month enrollment period. Include the DBRO screen front page (from IWD system) when referring these cases to hawk-i. Indicate in the comments section if there is any other unearned income on the NOD so it gets used.

When you make a referral and give the family a hawk-i brochure for informational purposes, take the application out of the brochure so they don‟t think they have to apply separately. This will help avoid duplicate applications being filed.

hawk-i Customer Service: 1-800-257-8563 (TDD: 1-888-422-2319) www.hawk-i.org

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Attachment 10 Plan Appeal and Grievance Procedures

UnitedHealthcare Wellmark Health Plan of Iowa Delta Dental of Iowa Definition Any questions or concerns regarding coverage decisions, preauthorization decisions, or any action concerning the provision of health care services, or other matters concerning the operations of health plan. Denial of benefits, or disagreement with decision to reduce benefits, or complaint regarding a claim, provider or service provided by Wellmark Denial or partial denial, or a complaint regarding a claim. Who can file a complaint or an appeal An Enrollee's physician, family member or other individual may act as the Enrollee's representative to assist in filing a complaint on behalf of the Enrollee. Enrollee or someone appointed by the Enrollee. The Enrollee, a representative of the Enrollee, or the dentist. Type of appeal

Informal Enrollee contacts Customer Service Department or other health plan employee with an inquiry. Enrollee calls Customer Service Department Enrollee calls Customer Service Department Decision maker Customer service department. If Enrollee is dissatisfied with the response, the enrollee must always be advised of next step in complaint process. Customer service department researches and resolve issue and notify Enrollee of right to appeal if appropriate Customer Service Department. If Enrollee disagrees with the decision, enrollee can receive a full and fair review. Standard or First Level Appeal Process Used for all cases that are not life threatening or severe enough to seriously jeopardize the member's health and/or ability to regain maximum function. Written expression of dissatisfaction with health plan requesting that a decision be overturned. If enrollee is not satisfied with resolution of a complaint, enrollee may contact customer service department by phone or submit a written appeal by completing an Enrollee Appeal Form. The enrollee may submit a written request of review and appeal. The written request should have the reason for the request, documents, records and any other information related to the claim. Time frames for filing an appeal Complaint form shall be filed within 90 days from date the problem in question occurred. The form shall be signed and the facts listed. The Enrollee Appeal Form must be filed within 120 days of the complaint decision. The written request should be submitted within 180 days from the notice of denial.

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UnitedHealthcare Wellmark Health Plan of Iowa Delta Dental of Iowa Decision maker Health plan's medical director or physician advisor when medical review is needed or appropriate. When the issue requires an administrative the appropriate department makes the decision. Persons involved in the initial determination may not review the appeal. Wellmark Blue Cross and Blue Shield Enrollee Appeal Committee Delta Dental Appeal Committee. Time frame for decision Within 30 calendar days of receipt of complaint with details of the decisions and further appeal process available to Enrollee, should decision not be in Enrollee's favor. The written decision may be extended by ten business days to obtain documentation records necessary to resolve the case and the delay is in the interest of the Enrollee. 30 calendar days from receipt of form, if no additional information is needed. If additional information is not received in time allowed, Wellmark will make a decision. Within 30 days of receiving the request. Notification of decision Written letter to all parties involved. Written letter to all parties involved. . Written letter to all parties involved. Expedited Appeal Requested to accommodate the urgency of the situation when the standard appeal process will cause delay in the rendering of health care that would be life threatening or severe enough to seriously jeopardize the member's health and/or ability to regain maximum function. May be requested anytime there is denial in utilization management and the situation is urgent. May be requested if the situation is urgent. Who can file a complaint or an appeal Enrollee or physician contacts UHC verbally or in writing with request for expedited appeal. An enrollee's physician, family member or other individual may act as the Enrollee's representative to assist in filing an appeal on behalf of the Enrollee.

Enrollee, physician or hospital The Enrollee, a representative of the Enrollee, or the dentist. Decision Maker Medical director or physician advisor Medical director or physician advisor Dental director or dental consultant.

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UnitedHealthcare Wellmark Health Plan of Iowa Delta Dental of Iowa Time frame for decision to be made Every attempt will be made to provide a decision for expedited appeals that are emergent in nature within 24 hour turnaround of receipt of complete medical information necessary to render a decision. Within 72 hours of request Every attempt is made to provide a decision as quickly as possible. Notification of decision The Enrollee will be informed of the decision by telephone or fax within 72 hours. In addition, a written decision is issued within 2 business days detailing the decision. If ruling is not in favor of the Enrollee, the Enrollee has 14 days to appeal the decision orally or in writing. By phone or fax, followed by written decision. By phone or fax, followed by a written decision. Second Level Appeal An appeal to Grievance Committee is a further request from an Enrollee than an unfavorable Level 1 complaint decision be reversed. If not satisfied with the resolution of first level appeal, Enrollee may appeal to the Enrollee Appeal Committee of the Board. A second request may be made if not satisfied with appeal decision. Time frame to file a second level appeal If the Enrollee is not satisfied with the outcome of the decision he/she has 14 days from the date the decision was issued in which to file a formal appeal to the Enrollee Grievance Committee of UHC. Must be filed within 30 calendar days of receipt of decision Must be filed within 30 days of receipt of the decision. Decision maker The Grievance Committee. Grievances will not be heard or voted upon unless at least 50% of the voting individuals of the committee are Enrollees who are consumers. The Grievance Committee shall have authority to resolve by majority vote grievances filed by Enrollees. The panel will include participants who were not involved in the previous decisions. A physician who was not previously involved will review the case when it involves a denial of services or treatment based on medical necessity. At least one Enrollee Appeal Committee of the Board Dental director or dental consultant.

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UnitedHealthcare Wellmark Health Plan of Iowa Delta Dental of Iowa practitioner in the same or similar specialty that typically manages the medical condition, procedure or treatment must be involved in the review at one level of the appeal process. Time for decision to be made Grievance Committee Hearing should be held within 45 days of the receipt of the appeal letter. An additional 30 day extension is avialable due to a delay in obtaining documents necessary for the Grievance Committee to make a deterimination. The Enrollee Appeal Committee of the Board will meet within 30 working days of receiving the appeal. The Enrollee Appeal Committee of the Board will issue a final decision and notify the Enrollee by letter within five business days of the meeting. Within 30 days from the date of receipt of the second request. Hearing notice information The Enrollee shall be notified, at the time of the hearing, of the name and affiliation of the Enrollee Grievance Committee members. UHC shall not present any evidence without the Enrollee having been given the opportunity to be present. Each party may present his or her case as to why the decision rendered should be sustained or rejected. The Enrollee shall have the right upon written request to review all documents. The Enrollee may submit issues and comments in writing. The Enrollee or someone acting on behalf of the enrollee may participate in the meeting of the Enrollee Appeal Committee of the Board. The Enrollee will receive a letter within five working days or receipt of appeal, acknowledging the receipt of the second level appeal and the date of the appeal meeting.

NA Notification of decision Final disposition letter detailing the reasoning of the decision, is mailed to the Enrollee within five business days after final decision by the Grievance Committee. The letter notifies the member of any further appeal rights they may have. A written decision is sent to all parties. A written decision is sent to all parties. External Review UHC shall not preclude the Enrollee from filing a complaint with the Department of If the Enrollee has exhausted the Plan's appeal process regarding a May appeal to the Iowa Insurance Commissioner.

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UnitedHealthcare Wellmark Health Plan of Iowa Delta Dental of Iowa Insurance nor shall it preclude the Department of Insurance from investigating a complaint persusant to its authority under section 4-6 of The HMO Act. denial of benefits based on medical necessity, the Enrollee or the provider acting on behalf of the Enrollee may request a decision of the Wellmark's decision with the Iowa Insurance Commissioner. This request must be filed in writing no later than 60 days following Wellmark's decision. Other review If a member is dissatisfied with the decision of the Member Grievance Committee, he or she may file a request for arbitration with UHC in writing within six months of the date of the decision. Arbitration shall be conducted in accordance with the Rules of the American Health Lawyers Association Alternative Dispute Resolution Service. The parties waive their right to jury trial, except for enforcement of the decision of the arbitrator. NA NA

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Attachment 11 Delta Dental of Iowa

This document is replaced with Attachment 15.

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Attachment 12 Wellmark Health Plan of Iowa (WHPI)

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Wellmark Health Plan of Iowa Member Handbook

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Attachment 13 hawk-i Health and Dental Plan Coverage Area Enrollment Effective March 1, 2009 County

Plans Adair Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Adams Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Allamakee Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Appanoose Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Audubon Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Benton Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Black Hawk Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Boone Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Bremer Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Buchanan Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Buena Vista Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Butler Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Calhoun Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Carroll Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Cass Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Cedar Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Cerro Gordo Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Cherokee Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Chickasaw Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Clarke Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Clay Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Clayton Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Clinton Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Crawford Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Dallas Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Davis Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Decatur Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Delaware Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Des Moines Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Dickinson Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Dubuque Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Emmet Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Fayette Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Floyd Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Franklin Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Fremont Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Greene Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Grundy Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Guthrie Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Hamilton Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Harding Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Harrison Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Henry Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Howard Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Humboldt Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Ida Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Iowa Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA

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Jackson Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Jasper Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Jefferson Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Johnson Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Jones Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Keokuk Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Lee Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Linn Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Louisa Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Lucas Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Lyon Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Madison Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Mahaska Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Marion Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Marshall Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Mills Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Mitchell Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Monona Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Monroe Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Montgomery Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Muscatine Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA O‟Brien Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Osceola Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Page Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Palo Alto Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Plymouth Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Pocahontas Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Polk Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Pottawattamie Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Poweshiek Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Ringgold Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Sac Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Scott Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Shelby Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Sioux Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Story Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Tama Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Taylor Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Union Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Van Buren Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Wapello Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Warren Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Washington Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Wayne Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Webster Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Winnebago Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Winneshiek Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Woodbury Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Worth Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA Wright Wellmark Health Plan of Iowa or United Healthcare, Delta Dental of IA

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Attachment 14 hawk-i Health and Dental Plan Disaster Coverage Area

As of July 9, 2008:

Iowa counties declared a disaster by the Governor of Iowa (24): Counties Adair Howard Palo Alto Appanoose Humboldt Pocahontas Audubon Henry Poweshiek Carroll Jackson Ringgold Cass Jefferson Shelby Clarke Lyon Taylor Grundy Montgomery Wayne Guthrie Monroe Winnebago

Presidential Declaration of Disaster for Individual Assistance (62 counties): Counties Adams Floyd Mahaska Allamakee Franklin Mills Benton Fremont Mitchell Bremer Greene Monona Black Hawk Hardin Muscatine Boone Hamilton Page Buchanan Harrison Polk Butler Hancock Pottawattamie Cedar Jasper Scott Cerro Gordo Johnson Story Chickasaw Jones Tama Clayton Iowa Union Clinton Keokuk Van Buren Crawford Kossuth Wapello Dallas Lee Washington Davis Linn Warren Dubuque Louisa Worth Decatur Lucas Webster Des Moines Madison Winneshiek Delaware Marion Wright

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Attachment 15 Outreach Results

Iowa’s CHIP Marketing Campaign Results from Jan 2008 – June 2009 In January 2008, we began an extensive media campaign with ZLR Ignition. The focus was on families earning less than $40,000 per year, which is made up primarily headed by adults age 18-49. The campaign skewed slightly towards females and used a variety of stations and materials to cover the racial and ethnic aspects of our population. The advertising vehicles included broadcast television, cable, radio, newspapers, gas pump toppers, bus transit and billboards. Broadcast television spots aired in all of Iowa‟s 99 counties. Cable television spots aired in 41 counties in 2008 and all 99 counties in 2009. Radio spots aired statewide for 24 weeks. o Radio extended the message to the hard-to-reach rural areas. o Radio advertisements were play specifically on African-American and Hispanic stations. o Total traffic sponsorship announcements aired to supplement the campaign. Newspaper advertisements included eight half-page ads, free standing insert in metro papers and a special section in 83 papers in 2008 and 75 papers in 2009 for “Cover the Uninsured Week”. The section‟s articles included hawk-i Helps Family Through Life-changing accident, Uninsured Kids at Greater Risk for Vaccine Preventable Diseases, Medicaid Provides Financial Lifeline, Tips to Raise Healthy Kids, and Study Finds Fewer Delays in Care, Better Overall Health for hawk-i covered Children. Gas pump toppers posted statewide from March to July in 2008 and then received bonus posting from August to October. Some stations also posted free window clings. Transit ads were posted in Sioux City, Dubuque, Cedar Rapids, Waterloo, Clinton and Des Moines. The Des Moines posting specifically included the Iowa State Fair buses. Outdoor billboards were posted between February and April in both metro and rural areas. They were strategically placed in counties with income below $40,000 year and to reach a diverse population. In addition, we received $1,019,400 dollar in add values advertisement through 3,543 broadcast TV PSA‟s, 27,262 cable TV PSA‟s, 3,067 bonus radio spots, and 2,496 extra posting days on billboards in 2008. In 2009 the Department received $680,570 in added values advertisement through 2,511 broadcast TV public service announcements, 51,988 cable TV public service announcements, 448 bonus radio spots, and $109,258 worth of extra posting days on billboards.

ZLR Ignition held kick-off events in Des Moines and Cedar Rapids; promoted Cover the Uninsured Week; and began Cover the Kids Day, where more than 1,000 churches shared information about hawk-i with their congregations. In addition, they also created the new hawk-i logo, designed new letterhead and redesigned the brochure cover, bookmark and website.

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The following chart show the enrollment changes since the media campaign began:

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Iowa’s Income Tax Return

For the 2008 tax form filed in 2009, the response rates of the 450,861 taxpayers who claimed at least one dependent child were:  13.7% of families reported the absence of health care coverage;  62.7% of families reported the presence of health care coverage; and  25.3% of families did not report. Department of Revenue cover letters with application brochures were sent to 57,450 potentially eligible households. Of these, 475 marked application brochures were returned and completed as follows:  140 applications were approved for hawk-i  191 applications were referred to Medicaid  1 pending  143 were denied for: Missing information was not received = 42 (29.5%) Over income = 28 (19.5%) Noncompliant with Medicaid = 47 (33%) Over age 19 = 7 (4.75%) Other health insurance = 6 (4%) Child did not live with applicant = 4 (3%) Home address not in Iowa = 2 (1.5%) Immigration document invalid or missing = 7 (4.75%) The results were that 471 (239 in hawk-i and 232 in Medicaid) previously uncovered children now have health care coverage. The costs for the project were $0.68 per household for materials and distribution. If you divide the cost by those children who now have health care coverage, the cost is $83.16 per applicant enrolled.

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Attachment 16 Iowa hawk-i Dental Plan

IOWA DEPARTMENT OF HUMAN SERVICES

The Iowa hawk-i Dental Plan

Covered Benefits

3/1/2010

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The Iowa hawk-i Dental Plan

If you are enrolled in this Plan, you are entitled to the benefits described below.

Cost Sharing: There are no copayments, deductibles or other cost sharing for this plan.

Annual Benefit Limit: There is a $1,000 benefit maximum per calendar year.

Exceptions to the $1,000 annual benefit maximum will be based on medical necessity and a prior authorization is required. For dental services to be paid above the $1,000 annual benefit maximum must allow a plan member to return to normal, pain and infection-free oral functioning. Typically this includes: Services related to the relief of significant pain or to eliminate acute infection; Services related to treat traumatic clinical conditions; Services that allow a patient to attain the basic human functions (e.g. eating, speech, etc.) Services that prevent a condition from seriously jeopardizing one‟s health/functioning or deteriorating in an imminent time frame to a more serious and costly dental problem.

Orthodontia Payment: Payment for medically necessary orthodontia services will be paid based on an approved treatment plan by the dental carrier and does not apply to the $1.000 benefit maximum.

Dental Providers: Please contact the dental carrier for information for a listing of approved dental providers. Delta Dental of Iowa: 1-866-544-0178 or http://www.deltadentalia.com/

hawk-i Program: For information on eligibility for the hawk-i program, call hawk-i customer services at 1-800-257-8563 or at www.hawk-i.org

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Section 1 - Basic Services The following is a list of services that are payable under the Iowa hawk-i Dental Plan. The list includes those services most commonly provided to covered individuals. It is not an all- inclusive list of covered services. Diagnostic and Treatment Services D0120 Periodic oral evaluation - Limited to 1 every 6 months D0140 Limited oral evaluation - problem focused - Limited to 1 every 6 months D0150 Comprehensive oral evaluation - Once per dentist in a three-year period when the recipient has not seen that dentist during the three years D0180 Comprehensive periodontal evaluation - Once per dentist in a three-year period when the recipient has not seen that dentist during the three years D0210 Intraoral – complete series (including bitewings) 1 every 60 (sixty) months D0220 Intraoral - periapical first film D0230 Intraoral - periapical - each additional film D0240 Intraoral - occlusal film D0270 Bitewing - single film - Children - 1 set every 12 months; 2 sets for “At High Risk” Children* D0272 Bitewings - two films - Children - 1 set every 12 months; 2 sets for “At High Risk” Children* D0274 Bitewings - four films - Children - 1 set every 12 months; 2 sets for “At High Risk” Children* D0277 Vertical bitewings – 7 to 8 films – Children - 1 set every 12 months; 2 sets for “At High Risk” Children* D0277 Vertical bitewings – 7 to 8 films – Children - 1 set every 12 months; 2 sets for “At High Risk” Children* D0330 Panoramic film – 1 film every 60 (sixty) months Preventive Services D1120 Prophylaxis – Child - Limited to 1 every 6 months D1203 Topical application of fluoride (excluding prophylaxis) – Limited to 2 every 12 months; additional application for “At High Risk” Children* D1204 Topical application of fluoride (excluding prophylaxis) – Age 15 to 18 - 2 every 12 months; additional applications for “At High Risk” Children* D1206 Topical fluoride varnish - Less than age 19 - 2 in 12 months; additional application for “At High Risk” Children* D1351 Sealant - per tooth - unrestored permanent molars - Less than age 18. 1 sealant per tooth every 36 months D1510 Space maintainer – fixed – unilateral -- Limited to children under age 19 D1515 Space maintainer – fixed – bilateral -- Limited to children under age 19 D1520 Space maintainer - removable – unilateral -- Limited to children under age 19 D1525 Space maintainer - removable – bilateral -- Limited to children under age 19 D1550 Re-cementation of space maintainer -- Limited to children under age 19 Additional Procedures covered as Basic Services D9110 Palliative treatment of dental pain – minor procedure * “At Risk” Children –as documented by provider using caries risk assessment form

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Section 2 - Intermediate Services The following is a list of services that are payable under the Iowa hawk-i Dental Plan. The list includes those services most commonly provided to covered individuals. It is not an all- inclusive list of covered services. Minor Restorative Services D2140 Amalgam - one surface, primary or permanent D2150 Amalgam - two surfaces, primary or permanent D2160 Amalgam - three surfaces, primary or permanent D2161 Amalgam - four or more surfaces, primary or permanent D2330 Resin–based composite - one surface, anterior D2331 Resin-based composite - two surfaces, anterior D2332 Resin-based composite - three surfaces, D2335 Resin-based composite - four or more surfaces or involving incisal angle (anterior) D2910 Re-cement inlay D2920 Re-cement crown D2930 Prefabricated stainless steel crown - primary tooth – Limited to 1 per tooth in 60 months D2931 Prefabricated stainless steel crown - permanent tooth - Limited to 1per tooth in 60 months D2951 Pin retention - per tooth, in addition to restoration Endodontic Services D3220 Therapeutic pulpotomy (excluding final restoration) - If a root canal is within 45 days of the pulpotomy, the pulpotomy is not a covered service since it is considered a part of the root canal procedure and benefits are not payable separately. D3222 Partial pulpotomy for apexogenesis - permanent tooth with incomplete root development If a root canal is within 45 days of the pulpotomy, the pulpotomy is not a covered service since it is considered a part of the root canal procedure and benefits are not payable separately. D3230 Pulpal therapy (resorbable filling) - anterior, primary tooth (excluding final restoration) - Limited to primary incisor teeth for members up to age 6 and for primary molars and cuspids up to age 11 and is limited to once per tooth per lifetime. D3240 Pulpal therapy (resorbable filling) - posterior, primary tooth excluding final restoration). Incomplete endodontic treatment when you discontinue treatment. - Limited to primary incisor teeth for members up to age 6 and for primary molars and cuspids up to age 11 and is limited to once per tooth per lifetime. Periodontal Services D4341 Periodontal scaling and root planning-four or more teeth per quadrant – Limited to 1 every 24 months D4342 Periodontal scaling and root planning-one to three teeth, per quadrant – Limited to 1 every 24 months D4910 Periodontal maintenance – 4 in 12 months combined with adult prophylaxis after the completion of active periodontal therapy Prosthodontic Services D5410 Adjust complete denture – maxillary D5411 Adjust complete denture – mandibular D5421 Adjust partial denture – maxillary D5422 Adjust partial denture - mandibular D5510 Repair broken complete denture base D5520 Replace missing or broken teeth - complete denture (each tooth) D5610 Repair resin denture base D5620 Repair cast framework

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D5630 Repair or replace broken clasp D5640 Replace broken teeth - per tooth D5650 Add tooth to existing partial denture D5660 Add clasp to existing partial denture D5710 Rebase complete maxillary denture - Limited to 1 in a 36-month period 6 months after the initial installation D5720 Rebase maxillary partial denture - Limited to 1 in a 36-month period 6 months after the initial installation D5721 Rebase mandibular partial denture - Limited to 1 in a 36-month period 6 months after the initial installation D5730 Reline complete maxillary denture (chairside) - Limited to 1 in a 36-month period 6 months after the initial installation D5731 Reline complete mandibular denture (chairside) - Limited to 1 in a 36-month period 6 months after the initial installation D5740 Reline maxillary partial denture (chairside) - Limited to 1in a 36-month period 6 months after the initial installation D5741 Reline mandibular partial denture (chairside) - Limited to 1 in a 36-month period 6 months after the initial installation D5750 Reline complete maxillary denture (laboratory) - Limited to 1 in a 36-month period 6 months after the initial installation D5751 Reline complete mandibular denture (laboratory) - Limited to 1 in a 36-month period 6 months after the initial installation D5760 Reline maxillary partial denture (laboratory) - Limited to 1 in a 36-month period 6 months after the initial installation D5761 Reline mandibular partial denture (laboratory) Rebase/Reline - Limited to 1 in a 36-month period 6 months after the initial installation. D5850 Tissue conditioning (maxillary) D5851 Tissue conditioning (mandibular) D6930 Recement fixed partial denture D6980 Fixed partial denture repair, by report Oral Surgery D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth D7220 Removal of impacted tooth - soft tissue D7230 Removal of impacted tooth – partially bony D7240 Removal of impacted tooth - completely bony D7241 Removal of impacted tooth - completely bony with unusual surgical complications D7250 Surgical removal of residual tooth roots (cutting procedure) D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth D7280 Surgical access of an unerupted tooth D7310 Alveoloplasty in conjunction with extractions/quadrant D7311 Alveoloplasty in conjunction with extractions-1-3 teeth or tooth spaces/quadrant D7320 Alveoloplasty not in conjunction with extractions - per quadrant D7321 Alveoloplasty not in conjunction with extractions-1-3 three teeth or tooth spaces/quadrant D7471 Removal of exostosis D7510 Incision and drainage of abscess - intraoral soft tissue D7910 Suture of recent small wounds up to 5 cm D7971 Excision of pericoronal gingiva

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Section 3 - Major Services The following is a list of services that are payable under the Iowa hawk-i Dental Plan. The list includes those services most commonly provided to covered individuals. It is not an all- inclusive list of covered services. Major Restorative Services D0160 Detailed and extensive oral evaluation - problem focused, by report D2510 Inlay - metallic – one surface – An alternate benefit will be provided D2520 Inlay - metallic – two surfaces – An alternate benefit will be provided D2530 Inlay - metallic – three surfaces – An alternate benefit will be provided D2542 Onlay - metallic - two surfaces – Limited to 1 per tooth every 60 months D2543 Onlay - metallic - three surfaces – Limited to 1 per tooth every 60 months D2544 Onlay - metallic - four or more surfaces – Limited to 1 per tooth every 60 months D2740 Crown - porcelain/ceramic substrate - Limited to 1 per tooth every 60 months D2750 Crown - porcelain fused to high noble metal - Limited to 1 per tooth every 60 months D2751 Crown - porcelain fused to predominately base metal – Limited to 1 per tooth every 60 mon D2752 Crown - porcelain fused to noble metal – Limited to 1 per tooth every 60 months D2780 Crown - 3/4 cast high noble metal – Limited to 1 per tooth every 60 months D2781 Crown - 3/4 cast predominately base metal – Limited to 1 per tooth every 60 months D2783 Crown - 3/4 porcelain/ceramic– Limited to 1 per tooth every 60 months D2790 Crown - full cast high noble metal– Limited to 1 per tooth every 60 months D2791 Crown - full cast predominately base metal – Limited to 1 per tooth every 60 months D2792 Crown - full cast noble metal– Limited to 1 per tooth every 60 months D2794 Crown – titanium– Limited to 1 per tooth every 60 months D2950 Core buildup, including any pins– Limited to 1 per tooth every 60 months D2954 Prefabricated post and core, in addition to crown– Limited to 1 per tooth every 60 months D2980 Crown repair, by report Endodontic Services D3310 Anterior root canal (excluding final restoration) D3320 Bicuspid root canal (excluding final restoration) D3330 Molar root canal (excluding final restoration) D3346 Retreatment of previous root canal therapy-anterior D3347 Retreatment of previous root canal therapy-bicuspid D3348 Retreatment of previous root canal therapy-molar D3351 Apexification/recalcification – initial visit (apical closure/calcific repair of perforations, root resorption, etc.) D3352 Apexification/recalcification – interim medication replacement (apical closure/calcific repair of perforations, rootresorption, etc.) D3353 Apexification/recalcification - final visit (includes completed root canal therapy, apical closure/calcific repair of perforations, root resorption, etc.) D3410 Apicoectomy/periradicular surgery - anterior D3421 Apicoectomy/periradicular surgery - bicuspid (first root) D3425 Apicoectomy/periradicular surgery - molar (first root) D3426 Apicoectomy/periradicular surgery (each additional root) D3450 Root amputation - per root D3920 Hemisection (including any root removal) - not including root canal therapy Periodontal Services D4210 Gingivectomy or gingivoplasty – four or more teeth Limited to 1 every 36 months

Effective Date:

Approval Date: 93

D4211 Gingivectomy or gingivoplasty – one to three teeth D4240 Gingival flap procedure, four or more teeth – Limited to 1 every 36 months D4249 Clinical crown lengthening-hard tissue D4260 Osseous surgery (including flap entry and closure), four or more contiguous teeth or bounded teeth spaces per quadrant – Limited to 1 every 36 months D4270 Pedicle soft tissue graft procedure D4271 Free soft tissue graft procedure (including donor site surgery) D4273 Subepithelial connective tissue graft procedures (including donor site surgery) D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis – Limited to 1 per lifetime Prosthodontic Services D5110 Complete denture - maxillary – Limited to 1 every 60 months D5120 Complete denture - mandibular – Limited to 1 every 60 months D5130 Immediate denture - maxillary – Limited to 1 every 60 months D5140 Immediate denture - mandibular – Limited to 1 every 60 months D5211 Maxillary partial denture - resin base (including any conventional clasps, rests and teeth) – Limited to 1 every 60 months D5212 Mandibular partial denture - resin base (including any conventional clasps, rests and teeth) – Limited to 1 every 60 months D5213 Maxillary partial denture - cast metal framework with resin denture base (including any conventional clasps, rests and teeth)– Limited to 1 every 60 months D5214 Mandibular partial denture - cast metal framework with resin denture base (including any conventional clasps, restsand teeth) – Limited to 1 every 60 months D5281 Removable unilateral partial denture-one piece cast metal (including clasps and teeth) – Limited to 1 every 60 months D6241 Pontic - porcelain fused to predominately base metal – Limited to 1 every 60 months D6242 Pontic - porcelain fused to noble metal – Limited to 1 every 60 months D6245 Pontic - porcelain/ceramic – Limited to 1 every 60 months D6519 Inlay/onlay – porcelain/ceramic – Limited to 1 every 60 months D6520 Inlay – metallic – two surfaces – Limited to 1 every 60 months D6530 Inlay – metallic – three or more surfaces 1 every 60 months D6543 Onlay – metallic – three surfaces 1 every 60 months D6544 Onlay – metallic – four or more surfaces 1 every 60 months D6545 Retainer - cast metal for resin bonded fixed prosthesis -1 every 60 months D6548 Retainer - porcelain/ceramic for resin bonded fixed prosthesis -1 every 60 months D6740 Crown - porcelain/ceramic -1 every 60 months D6750 Crown - porcelain fused to high noble metal - 1 every 60 months D6751 Crown - porcelain fused to predominately base metal - 1 every 60 months D6752 Crown - porcelain fused to noble metal - 1 every 60 months D6780 Crown - 3/4 cast high noble metal - 1 every 60 months D6781 Crown - 3/4 cast predominately base metal - 1 every 60 months D6782 Crown - 3/4 cast noble metal - 1 every 60 months D6783 Crown - 3/4 porcelain/ceramic - 1 every 60 months D6790 Crown - full cast high noble metal - 1 every 60 months D6791 Crown - full cast predominately base metal - 1 every 60 months D6792 Crown - full cast noble metal - 1 every 60 months D6973 Core buildup for retainer, including any pins - 1 every 60 months D9940 Occlusal guard, by report - 1 in 12 months for patients 13 and older

Effective Date:

Approval Date: 94

Section 4 - Orthodontic Coverage Orthodontic procedures require prior approval. Orthodontia procedures will be approved for handicapping malocclusions only. A “handicapping” malocclusion is a condition that constitutes a hazard to the maintenance of oral health and interferes with the well-being of the recipient by causing: • Impaired mastication, • Dysfunction of the temporo-mandibular articulation, • Susceptibility to periodontal disease, • Susceptibility to dental caries, and • Impaired speech due to malpositions of the teeth. Assessment of the most handicapping malocclusion is determined by the magnitude of the following variables: degree of malalignment, missing teeth, angle classification, overjet and overbite, open bite, and crossbite. A Salzman Index score of 26 or greater will be used as criteria for “medically necessary” benefits. Approval for treatment will be assessed in a manner consistent with “Handicapping Malocclusion Assessment to Establish Treatment Priority,” by J. A. Salzmann, DDS, American Journal of Orthodontics, October 1968. A request for prior approval shall be accompanied by documentation as directed by the dental plan to substantiate medically necessary orthodontic benefits. Post treatment records may be furnished upon request. Approval may be made a complete comprehensive case of active orthodontic treatment. Additional consideration for extenuated cases may be approved by the dental plan‟s orthodontic consultant if found to be medically necessary.

Minor Treatment To Control Harmful Habits D8210 Removable appliance therapy. Requires prior authorization. D8220 Fixed appliance therapy. Requires prior authorization.

Comprehensive Orthodontic Treatment Of Permanent Dentition/Transitional Dentition These procedures require prior authorization. Orthodontia procedures will be approved for documentation as directed by the dental plan to substantiate medically necessary orthodontic benefits.

Code Procedure Comment D0140 Limited Oral Evaluation D8070* Comprehensive treatment of transitional dentition D8080* Construct and place maxillary or mandibular appliance with retainer & active treatment D8210 Removable Appliance Therapy D8220 Fixed Appliance Therapy D8660 Pre-ortho visit/records D8680 Orthodontic retention D8690 Active treatment transfers . Use when recipient transfers from one provider to another. D8999 Unspecified orthodontic procedure

Effective Date:

Approval Date: 95

Section 5 – Services Not Covered The following is a list of services that are not payable under the Iowa hawk-i Dental Plan. Please Note: Even if a service is not specifically listed as an exclusion, it may not be covered under this plan. Contact the dental carrier if you are unsure a certain service is covered. Services Not Covered D0320 TMJ arthrogram D0321 Other TMJ films D0322 Tomographic survey D0360 Cone Beam CT D0362 Cone Beam multiple images 2 dim. D0363 Cone Beam multiple images 3 dim. D0416 Viral culture D0418 Analysis of saliva example chemical or biological analysis of saliva for disagnostic purposes. D0425 Caries test D0431 Adjunctive pre-diagnostic test D0475 Declassification procedure D0476 Special stains for microorganisms D0477 Special stains not for microorganisms D0478 Immunohistochemical stains D0479 Tissue in-situ-hybridization D0481 Electron microscopy D0482 Direct immunofluorescence D0483 In-direct immunofluorescence D0484 Consultation on slides prepared elsewhere D0485 Consultation including preparation of slides D0486 Brush biopsy sample D1310 Nutritional counseling D1320 Tobacco counseling D1330 Oral Hygiene Instruction D1555 Removal of fixed space maintainer D7292 Surgical replacement screw retained D7293 Surgical replacement w/surgical flap D7294 Surgical replacement without the surgical flap D7880 TMJ Appliance D7899 TMJ Therapy D7997 Appliance Removal D7998 Intraoral placement of a fixation device D2410 Gold Foil 1 surface D2420 Gold Foil 2 surface D2430 Gold Foil 3 surface D2799 Provisional Crown D2955 Post Removal D2970 Temporary Crown D2975 Coping D3460 Endodontic Implant

Effective Date:

Approval Date: 96

D3470 Intentional reimplantation D3910 Surgical procedure for isolation of tooth D3950 Canal preparation D4230 Anatomical crown exposure 4 or more teeth D4231 Anatomical crown exposure 1-3 teeth D4320 Splinting intracoronal D4321 Splinting extracoronal D5810 Complete denture upper (interim) D5811 Complete denture lower (interim) D5820 Partial denture upper (interim) D5821 Partial denture lower (interim) D5862 Precision Attachment D5867 Replacement Precision Attachment D5986 Fluoride Gel Carrier D6057 Custom abutment D6253 Provisional Pontic D6920 Connector bar D6940 Stress breaker D6950 Precision Attachment D6975 Coping – metal D9210 Local Anesthesia not in conjunction with operative or surgical procedures D9211 Regional Block Anesthesia D9212 Trigeminal Division Block Anesthesia D9215 Local Anesthesia D9230 Analgesia, anxiolysis, inhalation of nitrous oxide D9248 Non-intravenous conscious sedation D9410 House / extended care facility call D9420 Hospital Call D9450 Case presentation D9630 Other drugs and or medicaments D9920 Behavior Management D9941 Fabrication of athletic mouthguard D9950 Occlusion analysis - mounted case D9951 Occlusal adjustment - limited D9952 Occlusal adjustment - complete D9970 Enamel microabrasion D9971 Odontoplasty 1-2 teeth D9972 External bleaching - per arch D9973 External bleaching - per tooth D9974 Internal bleaching - per tooth D0310 Sialography D0472 Oral Pathology lab D0473 Oral Pathology lab D0474 Oral Pathology lab D0480 Oral Pathology lab D0502 Oral Pathology lab D5911 Facial Moulage (sectional) D5912 Facial Moulage (complete)

Effective Date:

Approval Date: 97

D5913 Nasal Prosthesis D5914 Auricular Prosthesis D5915 Orbital Prosthesis D5916 Ocular Prosthesis D5919 Facial Prosthesis D5922 Nasal Septal Prosthesis D5923 Ocular Prosthesis (interim) D5924 Cranial Prosthesis D5925 Facial Augmentation implant D5926 Nasal Prosthesis (replacement) D5927 Auricular Prosthesis (replacement) D5928 Orbital Prosthesis (replacement) D5929 Facial Prosthesis (replacement) D5931 Obturator Prosthesis (surgical) D5932 Obturator Prosthesis (definitive) D5933 Obturator Prosthesis (modification) D5934 Mandibular resection Prosthesis w/guide flange D5935 Mandibular resection Prosthesis w/out guide flange D5936 Obturator Prosthesis (interim) D5937 Trismus Appliance D5951 Feeding Aid D5952 Speech Aid prosthesis (pediatric) D5953 Speech Aid prosthesis (adult) D5954 Palatal Augmentation Prosthesis D5955 Palatal Lift Prosthesis (definitive) D5958 Palatal Lift Prosthesis (interim) D5959 Palatal Lift Prosthesis (modification) D5960 Speech Aid Prosthesis (modification) D5982 Surgical Stent D5983 Radiation Carrier D5984 Radiation Shield D5985 Radiation Cone locator D5987 Commissure Splint D5988 Surgical Splint D7285 Biopsy of oral tissue (hard) D7286 Biopsy of oral tissue (soft) D7410 Lesion up to 1.25 (benign) D7411 Lesion greater than 1.25 (benign) D7412 Complicated lesion (benign) D7413 Lesion up to 1.25 (malignant) D7414 Lesion greater than 1.25 (malignant) D7415 Complicated lesion (malignant) D7440 Lesion diameter up to 1.25 (malignant) D7441 Lesion diameter greater than 1.25 (malignant) D7460 Removal of Benign lesion up to 1.25 D7461 Removal of Benign lesion greater than 1.25 D7465 Destruction of lesion (by report) D7490 Radical resection upper/lower

Effective Date:

Approval Date: 98

D7530 Removal of foreign body D7540 Removal of reaction producing the foreign body D7550 Partial Ostectomy D7560 Maxillary Sinusotomy D7610 Upper open reduction D7620 Upper closed reduction D7630 Lower open reduction (simple) D7640 Lower closed reduction (simple) D7650 Open reduction (simple) D7660 Closed reduction (simple) D7670 Alveolus closed reduction (simple) D7671 Alveolus open reduction (simple) D7680 Facial bones (simple) D7710 Upper open reduction (compound) D7720 Upper closed reduction (compound) D7730 Lower open reduction (compound) D7740 Lower closed reduction (compound) D7750 Malar and/or zygomatic arch open red.(compound) D7760 Malar and/or zygomatic arch closed red.(compound) D7770 Alveolus open red.(compound - stabilization of teeth) D7771 Alveolus closed red. (compound – stabilization of teeth) D7780 Facial bones (compound) D7810 TMJ open reduction D7820 TMJ closed reduction D7830 TMJ manipulation D7840 Condylectomy D7850 Surgical discectomoy D7852 Disc repair D7854 Synovectomy D7856 Myotomy D7858 Joint reconstruction D7860 Arthrotomy D7865 Arthroplasty D7870 Arthrocentesis D7871 Non-Arthroscopic D7872 Arthroscopy with or without a biopsy D7873 Arthoscopy surgical adhesions D7874 Arthoscopy surgical disc D7875 Arthoscopy surgical synovectomy D7876 Arthoscopy surgical discectomy D7877 Arthoscopy surgical debridement D7911 Complicated sutures up to 5 cm. D7912 Complicated sutures greater than 5 cm. D7920 Skin graft D7940 Osteoplasty deformities D7941 Osteotomy lower rami D7943 Osteotomy lower rami with bone graft D7944 Osteotomy segmented

Effective Date:

Approval Date: 99

D7945 Osteotomy body of mandible D7946 Lefort I upper total D7947 Lefort I upper segmented D7948 Lefort II or Lefort III without bone graft D7949 Lefort II or Lefort III with bone graft D7950 Bone graft - mandible or face D7955 Repair of Maxillofacial soft or hard tissue D7980 Sialolithotomy D7981 Excision of salivary gland D7982 Sialodochoplasty D7983 Closure of salivary fistula D7990 Emergency tracheotomy D7991 Coronoidectomy D7995 Synthetic graft D7996 Implant lower for augmentation purposes

1 IOWA TITLE XXI PROGRAM & TITLE XXI AMENDMENT FACT SHEET

Name of Plan: Healthy and Well Kids in Iowa (hawk-i)

Date of Plan Submitted:

June 1, 1998 Date Plan Approved:

September 1, 1998 State Plan Effective Date:

July 1, 1998

Date Amendment #1 Submitted:

February 25, 1999 Date Amendment #1 Approved:

June 16, 1999 Amendment #1 Effective Date:

January 1, 1999

Date Amendment #2 Submitted:

December 29, 1999 Date Amendment #2 Approved:

March 31, 2000 Amendment #2 Effective Date:

October 1, 1999

Date Amendment #3 Submitted:

March 8, 2000 Date Amendment #3 Approved:

June 14, 2000 Amendment #3 Effective Date:

February 1, 2000

Date Amendment #4 Submitted:

September 27, 2000 Date Amendment #4 Approved:

December 18, 2000 Amendment #4 Effective Date:

July 1, 2000

Date Amendment #5 Submitted:

September 20, 2001 Date Amendment #5 Approved:

December 6, 2001 Amendment #5 Effective Date:

July 1, 2001

Date Amendment #6 Submitted:

June 26, 2002 Date Amendment #6 Approved:

September 19, 2002

Date Amendment #7 Submitted:

August 13, 2003 Date Amendment #7 Approved:

November 5, 2003 Date Amendment #7 Effective:

June 1, 2003

Date Amendment #8 Submitted:

June 20, 2005 Date Amendment #8 Approved:

September 7, 2005 Date Amendment #8 Effective:

July 1, 2004

Date Amendment #9 Submitted:

March 31, 2006 Date Amendment #9 Approved:

July 18, 2006 Date Amendment #9 Effective:

March 1, 2006

2 Date Amendment #10 Submitted: January 16, 2007 Date Amendment #10 Approved: April 9, 2007 Date Amendment #10 Effective:

July 1, 2006 (Health Plan Name Change)

July 24, 2006 (Adds Wellmark Plan of Iowa)

September 1, 2006 (Expands WHPI counties)

September 15, 2006 (Expand into 4 counties for

AmeriChoice and Delta Dental)

Date Amendment #11 Submitted: October 6, 2007 Date Amendment #11 Approved: April 24, 2008 Date Amendment #11 Effective:

July 1, 2007

Date Amendment #12 Submitted: June 30, 2008 Date Amendment #12 Approved: July 29. 2008 Date Amendment #12 Effective:

June 1, 2008

Date Amendment #13 Submitted: February 24, 2009 Date Amendment #13 Approved: September 18, 2009 Date Amendment #13 Effective:

July 1, 2009

Background

• On June 1, 1998, Iowa submitted a Title XXI State Plan to provide health insurance coverage to uninsured children through an expansion of the State’s Title XIX Medicaid program. The Plan provides Medicaid Expansion coverage to children ages 6 through 18 in families with income from 100 percent up to 133 percent of the Federal Poverty Level (FPL).

Amendments

• On February 25, 1999, the State submitted an amendment, effective January 1, 1999, to its approved Title XXI plan. This amendment, entitled the hawk-i program, is the non- Medicaid component of Iowa’s CHIP program. Hawk-i provides health care coverage, via contracts with commercial health care plans, to children whose family income does not exceed 185 percent of the FPL.

• On December 29, 1999, the State submitted an amendment, effective October 1, 1999, to its approved Title XXI plan. This amendment allows for a 20-percent deduction to earned income in determining eligibility for the hawk-i program, and includes an additional managed health care plan, Unity Choice from Wellmark Health Plan of Iowa.

• On March 8, 2000, the State submitted an amendment, effective February 1, 2000, to its approved Title XXI plan. This amendment adds a third managed health care plan, John Deere Health Plan to selected counties in Iowa. The amendment also removes cost sharing for American Indian/Alaska Native children and also allows a deduction for depreciation of capital assets when considering self-employment income.

3 • On September 27, 2000, the State submitted an amendment to its approved Title XXI plan. This amendment expands coverage under the Medicaid Expansion program for infants up to 1 year of age in families with incomes at or below 200 percent of the FPL. In addition, it expands coverage under the hawk-i program to children up to age 19 in families with income from 185 percent of the FPLP up to 200 percent of the FPL.

• On September 20, 2001, the State submitted an amendment to its approved Title XXI plan. Unity Choice from Wellmark Health Plan of Iowa is no longer participating as a managed health plan in hawk-i. The Iowa counties that Unity Choice had been covering are now covered by John Deere Health Plan of Iowa, Iowa Health Solutions, or Classic Blue from Wellmark Blue Cross Blue Shield of Iowa.

• On June 26, 2002, the State submitted an amendment to update and amend the CHIP State Plan to indicate the State’s compliance with the final CHIP regulations.

• On August 13, 2003, the State submitted an amendment to eliminate the 6-month waiting period for uninsured children who have been insured through an employer sponsored health plan in the 6 months prior to application for hawk-i and to indicate the expansion of Iowa Health Solutions coverage under the State's hawk-i program to two additional counties. This amendment also updates the effective date in the State plan to specify when Iowa began allowing depreciation of capital assets as a deduction to self- employment income.

• On June 20, 2005, the State submitted its eighth amendment to revise the process for children who no longer qualify for Medicaid to be referred to the hawk-i program; allow dental plans to participate in the hawk-i program; remove Iowa Health Solutions as a participating health plan in the hawk-i program; allow individuals to apply for the hawk-i program through the Internet; and revise the strategic objectives and performance goals.

• On March 31, 2006, the State submitted its ninth CHIP amendment to change the health care provider in 20 counties from Classic Blue (Wellmark Blue Cross Blue Shield of Iowa) to the John Deere Health Plan.

• On January 16, 2006, the State submitted its tenth CHIP amendment to make the following changes: (1) added a new managed care plan, Wellmark Health Plan of Iowa (WHPI) effective July 24, 2006. WHPI also expanded into 26 counties effective September 1, 2006, (it now covers a total of 69 counties in the State); (2) AmeriChoice and Delta Dental Health Plan of Iowa expanded into four counties (Carroll, Des Moines, Fayette, and Wayne) effective September 15, 2006; and, (3) changed the name of UnitedHealthcare of the River Valley to AmeriChoice, effective July 1, 2006. With this amendment approval, hawk-i members now have a choice of managed care plans in 43 counties in the State. Also, 27 counties are covered by a single managed care plan and the remaining 29 counties are covered by an indemnity plan.

• On October 6, 2007, Iowa submitted its eleventh amendment. This amendment revises the CHIP State plan by expanding the number of counties served by Wellmark Health Plan of Iowa and decreases the number of counties served by Wellmark Blue Cross Blue

4 Shield of Iowa. This amendment increases the total number of managed care counties to 82 and 17 fee for service counties remain.

• On June 23, 2008, Iowa submitted its twelfth amendment. With approval of this SPA, Iowa will be granting hardship exemptions to CHIP enrollees for premium payments when they are residing in a county in which a national disaster has been declared by FEMA. Premiums will be forgiven for the months of June and July 2008.

• On February 24, 2009, Iowa submitted its thirteenth amendment to expand the eligibility for children in its CHIP up to 300 percent of the FPL, using a block of income disregards. Additionally, the amendment allowed Iowa to continue utilizing a 20 percent income disregard in establishing income levels for purposes of determining premium amounts ($20 per month per child up to a family maximum of $40 per month) for the new expansion group. The State revised its submission to include a 30-day waiting period of uninsurance for CHIP coverage, only for children with family incomes above 250 percent of the FPL up to 300 percent of the FPL. Children with lower family incomes will not be subject to the 30-day waiting period. The State details a list of exceptions to the 30-day waiting period in the State plan. This SPA has a retroactive effective date of July 1, 2009.

Children Covered Under Program

• The State reported that there were 50,390 children ever enrolled in CHIP combination program during Federal Fiscal Year 2008, of which 17,709 were in the Medicaid expansion Program and 32,681 were enrolled in the Separate child health plan.

Administration

• The Department of Human Services (DHS) has contracted with a third-party administrator to provide, at a minimum, the following services for the non-Medicaid CHIP (hawk-i): distributes applications; determines eligibility; screens for Medicaid eligibility and coordinates with Medicaid Eligibility Worker; calculates, bills, and collects cost sharing; assists the family in selecting a health plan and enrolling the child in the selected plan; gathers encounter data from the health plans; and provides DHS with demographic, statistical, and encounter data for Federal reporting.

Health Care Delivery System

• For the hawk-i program, the State contracts with commercial insurers to deliver services for CHIP populations. Both fee-for-service and managed care plans may participate.

Benefit Package

• The hawk-i program provides benchmark-equivalent coverage.

• Iowa’s CHIP plan is richer than the State employees’ benchmark plan because State employees must pay additional copayments.

5

• Hawk-i enrollees receive health and dental benefits through: AmeriChoice, Wellmark Blue Cross Blue Shield, Delta Dental and Wellmark Health Plan of Iowa.

Cost Sharing

• Iowa continues to utilize a 20 percent income disregard in establishing income levels for purposes of determining premium amounts. Hawk-i premiums are $10 per child per month, with a maximum of $20 per family for families whose income is at or above 150 percent up to 200 percent of the FPL; and premiums are $20 per child per month, with a maximum of $40 per family for families whose net income is above 200 percent but up to and including 300 percent of the FPL.

• Families whose countable income is equal to or greater than 150 percent of the FPL shall be assessed a $25 copayment for each emergency room visit if the child’s medical condition does not meet the definition of emergency medical condition.

• At current poverty levels, the family would have to incur the number of inappropriate

emergency room (ER) visits indicated below to exceed 5 percent. Health plans will report enrollee ER usage, resulting in a copayment obligation, to the third party administrator. The third party administrator will track the ER copayment to ensure cost sharing does not exceed 5 percent of the family income. At the point the ER copayment results in cost sharing exceeding 5 percent, enrollees will be reimbursed for the cost. Number of children in family Annual Income at 300% FPL 5% Premium Maximum 5% minus premium maximum

No. of Annual Inappropriate ER Visits 1 $32,490 $1,624.50 $240 $1,384.50 ($1384.50/$25) 55 2 $43,710 $2,185.50 $480 $1,705.50 ($1705.50/$25) 68 3 $54,930 $2,746.50 $480 $2,266.50 ($2266.50/$25) 91 4 $66,150 $3,307.50 $480 $2,827.50 ($2827.50/$25) 113 5 $77,370 $3,868.50 $480 $3,388.50 ($3388.50/$25) 136 6 $88,590 $4,429.50 $480 $3,949.50 ($3949.50/$25) 158 7 $99,810 $4,990.50 $480 $4,510.50 ($4510.50/$25) 180 8 $111,030 $5,551.50 $480 $5,071.50 ($5071.50/$25) 203

• There is no cost sharing for Native American/Alaskan Native children.

6 State Action to Avoid Crowd Out

• The State monitors for substitution by asking insurance history questions on the application form, which is then tracked by the State's third-party administrator.

• For children applying to the hawk-i program, a match with insurance carriers is done to determine if the children have other health care coverage. For all hawk-i applicants, the State will monitor the length of time between when other coverage ended and the time the child applied, to determine if additional strategies are needed.

• The State has also included a 30-day waiting period of uninsurance for CHIP coverage, only for children with family incomes above 250 percent of the FPL up to 300 percent of the FPL. Children with lower family incomes will not be subject to the 30-day waiting period. The list of exceptions to the 30-day waiting period includes:

o lack of affordability , if the child’s premiums are greater than 5 percent of the family’s income; o existence of a chronic or emergent medical condition; o current coverage is through an individual plan rather than under group coverage; o for domestic violence, divorce or death of a parent; o the involuntary loss of employment or change in employment; o the child reaches a maximum lifetime coverage amount; o coverage under COBRA expires; and o a discontinuation of the availability of dependent coverage.

Coordination between CHIP and Medicaid

• All applications are screened for Medicaid eligibility and the presence of health insurance coverage. The hawk-i application is also used as an application for Medicaid benefits. If it appears that the child is eligible for Medicaid, the hawk-i application will be forwarded to the Eligibility Worker for obtaining the social security number, any necessary child support information, and an eligibility review.

• If the applicant is not Medicaid eligible, hawk-i eligibility is determined. If the child has health insurance coverage and is not Medicaid-eligible, coverage under hawk-i is denied.

• When an application is screened for Medicaid eligibility and it is determined that the child does not qualify or will no longer qualify for Medicaid due to excess income, a referral is made to hawk-i. The referral can be accomplished either electronically or using a paper form. In either format, the referral includes the name of the child (or children), the Medicaid application date (for children denied Medicaid) or the Medicaid end date (for children cancelled from Medicaid), and the reason for the referral. The electronic referral also includes the income amounts used to determine Medicaid ineligibility. A copy of the Medicaid notice of decision denying or canceling Medicaid accompanies the paper referral. This notice contains a calculation showing how Medicaid ineligibility due to excess income was determined.

7 Outreach Activities

• The State has been educating the public about hawk-i through presentations by staff at various conferences and organizational meetings (school nurse’s conferences, Des Moines Chamber of Commerce, Women, Infant, and Children Program, Headstart).

• DHS and the Department of Education through an interagency agreement connected participants in the Free and Reduced Meals Program with referrals to hawk-i. A Back-to- School Radio Campaign was held, which was also advertised in Spanish.

• Multiple outreach activities are taking place in Iowa to reach multiple audiences, at both the statewide and local level. Iowa provides outreach to schools, physicians, childcare agencies, employers and insurance agencies to name a few.

Financial Information

Total FFY ’09 CHIP Allotment – $65,255,300 FFY ‘09 Enhanced Matching Rate – 73.83%

Date Last Updated: CMS, CMSO, FCHPG, DSCHI, October 2, 2009

_____________________________________________________________________________

Table of Contents

State/Territory Name: Iowa

State Plan Amendment (SPA) #: IA-13-0018

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages

The complete title XXI state plan for Iowa consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: XXI state plans and amendments: http://medicaid.gov/chip/state-program-information/chipstate- program-information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: S2-01-16 Cc M Ss

Baltimore, Maryland 21244-1850 CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

MAR 14 2014

Charles M. Palmer, Director

Iowa Department of Human Services Hoover State Office Building

1305 East Walnut, 5" Floor

Des Moines, IA 50319

Dear Mr. Palmer:

Iam pleased to inform you that the Centers for Medicare & Medicaid Services has approved your Children’s Health Insurance Program (CHIP) state plan amendmetit (SPA) number IA-13-0018, submitted on December 30, 2013, and related Modified Adjusted Gross Income (MAGI) Eligibility, with an effective date of January 1, 2014.

In SPA number JA-13-0018, page CS15 provides assurance that the state will apply methodologies based on MAGI for all separate CHIP covered groups. Page CS7 indicates that, using the approved MAGI conversion plan income thresholds, the state will cover targeted low- income children. And page CS12 indicates that the state will provide supplemental dental coverage to insured children who would otherwise be eligible for CHIP as targeted low-income children. A copy of the approved CS15 is attached and should be incorporated within a separate subsection under Section 4.3 of the state’s approved CHIP state plan. A copy of the approved ~ CS7 is attached and supersedes the current Geographic Area, Age and Income sections 4.1.1, 4.1.2 and 4.1.3 of the current CHIP state plan. Also, a copy of the approved CS12 is attached

and supersedes the current Section 4.1-DS of the current CHIP state plan.

Your title XXI project officer is Mr. Martin Burian. He is available to answer questions concerning this amendment. Mr. Burian’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services

7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850

Telephone: (410) 786-3246

Facsimile: (410) 786-5882

E-mail: Martin.Burian@cms.bhs.gov

Page 2 — Mr. Charles M. Palmer

Official communications regarding program matters should be sent simultaneously to Mr. Burian and to Mr. James G. Scott, Associate Regional Administrator in our Kansas City Regional Office. Mr. Scott’s address is:

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations Richard Bolling Federal Building

601 East 12" St, Room 355

Kansas City, MO 64103-2808

If you have additional questions, please contact Ms. Linda Nablo, Director, Division of State Coverage Programs at (410) 786-5143. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SPAs.

Sincerely, Eliot Fishman Director Enclosures ce:

James G. Scott, ARA, CMS Region VII

SE ES cCcMs CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

CS7

2102(b)(1)(B)(v) of the SSA and 42 CFR 457.310, 315 and 320

fay Targeted Low-Income Children - Uninsured children under age 19 whose household income is within standards established by the state.

The CHIP Agency operates this covered group in accordance with the following provisions: Age Must be under age 19.

Income Standards

Income standards are applied statewide.

Are there any exceptions, e.g. populations in a county which may qualify under either a statewide income standard or a county income standard?

No

Statewide Income Standards

Begin with lowest age range first.

Please note that the lower bound for CHIP eligibility should be the highest standard used for Medicaid poverty- level children for the same age group or groups entered here.

From Age To Age Above (% FPL) Up to & including (% FPL)

*+ i 19 167 302 x

Age ranges may overlap. If there is an overlap, provide an explanation. Include the age ranges for each income standard that has overlapping ages and the reason for having different income standards.

Special Program for Children with Disabilities

Does the state have a special program for children with disabilities? | No

PRA Disclosure Statement

MAR 14 2014

SPA# IA-13-0018 Approval Date: Effective Date: January 1, 2014 Page | of 2

ccmMs CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance ‘Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130709

SPA# IA-13-0018 Approval Date: MAR 14 2014

Effective Date: January 1, 2014 Page 2 of 2

CMs CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

Separate Child Health Insurance Progran Eligibility - Dental Only Supplemental C

CS12

Section 2110(b)(5) of the SSA

iw Dental Only Supplemental Coverage - Coverage to targeted low-income children who are otherwise eligible for CHIP but for the fact that they are enrolled in a group health plan or health insurance offered through an employer.

The CHIP Agency operates this covered group in accordance with the following provisions:

Income Standards

The state uses the same income standards for Dental only supplemental coverage as are used for other targeted low income No children.

Income standards are applied statewide.

Are there any exceptions, e.g. populations in a county which may qualify under either a statewide income No standard or a county income standard?

Statewide Income Standards

Begin with lowest age range first.

The upper end of the income range may not exceed the highest income level for targeted low-income children of the same age.

From Age To Age Above (% FPL) Up to & including (% FPL)

+ fl 19 167 302 x

Age ranges may overlap. If there is an overlap, provide an explanation. Include the age ranges for each income standard that has overlapping ages and the reason for having different income standards.

The state provides assurance that the state has the highest income eligibility standard permitted under Title XXI (or a waiver) as of January 1, 2009, in order to be able to provide Dental only supplemental coverage.

The state provides assurance that the state does not limit the acceptance of applications for children or impose any numerical limitation, waiting list, or similar limitation on the eligibility of such children for child health assistance under the state plan.

PRA Disclosure Statement SPA# IA-13-0018 Approval Date: MAR 1 4 2014

Effective Date: January 1, 2014 Page | of 2

ccmMs CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130709

SPA# IA-13-0018 Approval Date: MAR 1 4 2014 Effective Date: January 1, 2014

Page 2 of 2

CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

CS15

Separate Child Health Insurance Program MAGI-Based Income Methodologies :

2102(b)(1)(B)(v) of the SSA and 42 CFR 457.315

w The CHIP Agency will apply Modified Adjusted Gross Income methodologies for all separate CHIP covered groups, as described below, and consistent with 42 CFR 457.315 and 435.603(b) through (i).

In the case of determining ongoing eligibility for enrollees determined eligible for CHIP on or before December 31, 2013, MAGI- based income methodologies will not be applied until March 31, 2014 or the next regularly-scheduled renewal of eligibility, whichever is later.

If the state covers pregnant women, in determining family size for the eligibility determination of a pregnant woman, she is counted as herself plus each of the children she is expected to deliver.

In determining family size for the eligibility determination of the other individuals in a household that includes a pregnant woman: C The pregnant woman is counted just as herself. C The pregnant woman is counted just as herself, plus one. @ The pregnant woman is counted as herself, plus the number of children she is expected to deliver. Financial eligibility is determined consistent with the following provisions: When determining eligibility for new applicants, financial eligibility is based on current monthly income and family size. When determining eligibility for current beneficiaries, financial eligibility is based on: @ Current monthly household income and family size. C Projected annual household income for the remaining months of the current calendar year and family size. In determining current monthly or projected annual household income, the state will use reasonable methods to: (J) Include a prorated portion of the reasonably predictable increase in future income and/or family size.

(J Account for a reasonably predictable decrease in future income and/or family size.

Except as provided at 42 CFR 457.315 and 435.603(d)(2) through (d)(4), household income is the sum of the MAGI-based income of every individual included in the individual's household.

Household income includes actually available cash support, exceeding nominal amounts, provided

by the person claiming an individual described at §435.603(f)(2)(i) as a tax dependent. °

The CHIP Agency certifies that it has submitted and received approval for the conversion for all separate CHIP covered group income standards to MAGI-equivalent standards.

An attachment is submitted.

PRA Disclosure Statement

MAR 14 2016

SPA# IA-13-0018 Approval Date: Effective Date: January 1, 2014

Page | of 2

ccmMs CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

MAR 1 4 2014

SPA# IA-13-0018 Approval Date: Effective Date: January 1, 2014

Page 2 of 2

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility IA.0685.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Iowa State Funds: $ Federal Funds: $ Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST- YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. IA-13-0018 Type of SPA:  MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 2102(b)(1)(B)(v) of the SSA and 42 CFR 457.310,315,320, 457.315; Section 2110(b)(5) of t Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Page 1 of 2 Children's Health Insurance Program Eligibility: Summary Page 09/14/2016 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01...

Submitted By: Anna Ruggle Last Revision Date: Feb 19, 2014 Submit Date: Dec 30, 2013 Character Count:73 out of 2000   This SPA identifes the Modified Adjusted Gross Income (MAGI) eligibility. Signature of State Agency Official FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: Summary Page 09/14/2016 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01...

_____________________________________________________________________________

Table of Contents

State/Territory Name: Iowa

State Plan Amendment (SPA) #: IA-13-0019

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages

The complete title XXI state plan for Iowa consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: XXI state plans and amendments: http://medicaid.gov/chip/state-program-information/chipstate- program-information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: 82-26-12 (CMS

Baltimore, Maryland 21244-1850 CENTERS FOR MEDICARE & MEDICAID SERVICES

CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

JUN 47 2014

Charles M. Palmer, Director

Iowa Department of Human Services Hoover State Office Building

1305 East Walnut, 5" Floor

Des Moines, IA 50319

Dear Mr. Palmer:

Tam pleased to inform you that the Centers for Medicare & Medicaid Services has approved your Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number IA-13-0019 submitted on December 30, 2013, with additional information provided on June 9, 2014. This SPA relates to Modified Adjusted Gross Income (MAGI) Eligibility and has an effective date of January 1, 2014.

The SPA number IA-13-0019 converts the state’s existing income eligibility standards to MAGI- equivalent standards, by age group, for children covered in its title XXI-funded Medicaid program. A copy of the approved state plan page (CS3) is attached, and should be incorporated into the state’s approved CHIP state plan. This page supersedes the current Medicaid expansion Section (4.0) of the current CHIP state plan.

Your title XXI project officer is Mr. Martin Burian. He is available to answer questions concerning this amendment. Mr. Burian’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services

7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850

Telephone: (410) 786-3246

Facsimile: (410) 786-5882

E-mail: Martin.Burian@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Mr. Burian and to Mr. James G. Scott, Associate Regional Administrator (ARA) in our Kansas City Regional Office. Mr. Scott’s address is:

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations Richard Bolling Federal Building

601 East 12" Street, Room 355

Kansas City, MO 64103-2808

Page 2 — Mr. Charles M. Palmer

Congratulations on the approval. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SPAs. If you have additional questions, please contact Ms. Barbara K. Richards, Acting Director, Division of State Coverage Programs at (410) 786-5920.

Sincerely, Eliot Fishman Director Enclosure ce:

James G. Scott, ARA, CMS Region VII

cems CHIP Eligibility

OMB C

42 CFR 457.320(a)(2) and (3)

Income eligibility for children under the Medicaid Expansion is determined in accordance with the following income standards: There should be no overlaps or gaps for the ages entered.

Age and Household Income Ranges

From Age To Age Above (% FPL) Up to & including (% FPL) I 240 375 19 122 167

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

JUN i 7 2014 Effective Date: January 1, 2014

Page | of |

SPA# IA-13-0019 Approval Date:

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility IA.0686.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Iowa State Funds: $ Federal Funds: $ Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST- YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. IA-13-0019 Type of SPA: MAGI Eligibility & Methods  XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 457.320(a)(2) and (3) Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Page 1 of 2 Children's Health Insurance Program Eligibility: Summary Page 09/14/2016 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01...

Submitted By: Anna Ruggle Last Revision Date: Dec 31, 2013 Submit Date: Dec 30, 2013 Character Count:53 out of 2000   New federal poverty levels based on MAGI calculations Signature of State Agency Official FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: Summary Page 09/14/2016 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01...

_____________________________________________________________________________

Table of Contents

State/Territory Name: Iowa

State Plan Amendment (SPA) #: IA-13-0020

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages

The complete title XXI state plan for Iowa consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: XXI state plans and amendments: http://medicaid.gov/chip/state-program-information/chipstate- program-information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: S2-01-16 Cc M Ss

Baltimore, Maryland 21244-1850 CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

MAR 14 2014

Charles M. Palmer, Director

Iowa Department of Human Services Hoover State Office Building

1305 East Walnut, 5" Floor

Des Moines, IA 50319

Dear Mr. Palmer:

I am pleased to inform you that the Centers for Medicare & Medicaid Services has approved your Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number IA-13-0020, submitted on December 30, 2013, and related Modified Adjusted Gross Income (MAGI) Eligibility, with an effective date of January 1, 2014.

The SPA number IA-13-0020 describes the state’s plan to provide coverage in its separate CHIP, for children subject to Section 2101(f) of the Affordable Care Act, as specified in the state’s submission of CS14: Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards. A copy of the approved state plan page (CS14) is attached, and should be incorporated within a separate subsection under Section 4.1 of Jowa’s approved CHIP state plan.

Your title XX] project officer is Mr. Martin Burian. He is available to answer questions concerning this amendment. Mr. Burian’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services

7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850

Telephone: (410) 786-3246

Facsimile: (410) 786-5882

E-mail: Martin.Burian@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Mr. Burian and to Mr. James G. Scott, Associate Regional Administrator in our Kansas City Regional Office. Mr. Scott’s address is:

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations Richard Bolling Federal Building

601 East 12" St, Room 355

Kansas City, MO 64103-2808

Page 2 ~ Mr. Charles M. Palmer

If you have additional questions, please contact Ms. Linda Nablo, Director, Division of State Coverage Programs at (410) 786-5143. We look forward to continuing to work with you and your staff toward the approval of your remaining MAGI Eligibility SPAs.

Sincerely, Eliot Fishman Director Enclosure ce:

James G. Scott, ARA, CMS Region VII

cms. CHIP Eligibility

OMB Control Number: 0938-1148 Exprration date: 10/31/2014

CS14

Child Health Insurance Progr: eS : Ce Eligibility - Children Ineligible or Medicaid a as a Result of the E imination of Income Disreosrds

Section 2101(f) of the ACA and 42 CFR 457.310(d)

[im] Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards

The CHIP agency provides coverage for this group of children as follows:

The state has received approval from CMS to maintain Medicaid eligibility for children who would otherwise be subject to Section 2101(f) such that no child in the state will be subject to this provision.

The state assures that separate CHIP coverage will be provided for children ineligible for Medicaid due to the elimination of

= income disregards in accordance with 42 CFR 457.310(d). Coverage for this population will cease when the last child protected * from loss of Medicaid coverage as a result of the elimination of income disregards has been afforded 12 months of coverage in a separate CHIP (expected to be no later than April 1, 2016 ).

Describe the methodology used by the state to identify and enroll children in a separate CHIP who are subject to the protection afforded by Section 2101(f) of the Affordable Care Act:

The state has demonstrated and CMS has agreed that all children qualifying for section 2101(f) protection will qualify for the state’s existing separate CHIP.

The state will enroll all children in a separate CHIP who lose Medicaid eligibility because of an increase in family income at their first renewal applying MAGI methods.

The state will enroll children in a separate CHIP whose family income falls above the converted MAGI Medicaid FPL but at or below the following percentage of FPL. The state has demonstrated and CMS has agreed that all or almost all the children who would have maintained Medicaid eligibility if former disregards were applied will be within this income range and therefore covered in the separate CHIP.

(% FPL

The state will enroll children in a separate CHIP who are found to be ineligible for Medicaid based on MAGI but whose family income has not increased since the child’s last determination of Medicaid eligibility or who would have remained eligible for * Medicaid (based on the 2013 Medicaid income standard) if the value of their 2013 disregards had been applied to the family income as determined by MAGI methodology.

C Other.

Describe the benefits provided to this population:

C This population will be provided the same benefits as are provided to children in the state’s Medicaid program. @ This population will be provided the same benefits as are provided to children in the state's separate CHIP.

C Other (consistent with Section 2103 of the SSA and 42 CFR 457 Subpart D).

Describe premiums and cost sharing required of this population:

C Cost sharing is the same as for children in the Medicaid program.

14 SPA# IA-13-0020 Approval Date: MAR { 4 2 Effective'Date: January 1, 2014

Page | of 2

cms. CHIP Eligibility

@ Premiums and cost sharing are the same as for targeted low-income children in the state's separate CHIP. C No premiums, copayments, deductibles, coinsurance or other cost sharing is required.

C Other premiums and/or cost-sharing requirements (consistent with Section 2103(e) of the SSA and 42 CFR 457 Subpart E).

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SPA# IA-13-0020 Approval Date: MAR 1 4 2014 Effective Date: January 1, 2014

Page 2 of 2

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility IA.0687.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Iowa State Funds: $ Federal Funds: $ Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST- YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. IA-13-0020 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion  Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation Section 2101(f) of the ACA and 42 CFR 457.310(d) Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Page 1 of 2 Children's Health Insurance Program Eligibility: Summary Page 09/14/2016 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01...

Submitted By: Anna Ruggle Last Revision Date: Dec 31, 2013 Submit Date: Dec 30, 2013 Character Count:110 out of 2000   This SPA allows for coverage of previously covered Medicaid children who lose eligibity due to MAGI under CHIP Signature of State Agency Official FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: Summary Page 09/14/2016 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01...

_____________________________________________________________________________

Table of Contents

State/Territory Name: Iowa

State Plan Amendment (SPA) #: IA-13-0021

This file contains the following documents in the order listed:

1) Approval Letter 2) Companion Letter 3) SPA Summary Form 4) Approved SPA Pages 5) Additional Attachments that are Part of the State Plan

The complete title XXI state plan for Iowa consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: http://medicaid.gov/Medicaid-CHIP-Program-Information/By- Topics/Childrens-Health-Insurance-Program-CHIP/CHIP-State-Program-Information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: S2-26-12

Children and Adults Health Programs Group

MAR 2 6 2014

Charles M. Palmer, Director

Iowa Department of Human Services Hoover State Office Building

1305 East Walnut, 5" Floor

Des Moines, IA 50319-0119

Dear Mr. Palmer:

I am pleased to inform you that the Centers for Medicare & Medicaid Services (CMS) has approved Iowa’s Children’s Health Insurance Program (CHIP) state plan amendment (SPA), IA- 13-0021, submitted on December, 30, 2013. This SPA incorporates the MAGI-based eligibility process requirements in accordance with the Affordable Care Act. The effective date of this SPA is October 1, 2013.

The state is using interim alternative single streamlined paper and online applications and by December 31, 2014, will implement revised alternative single streamlined paper and online applications that address CMS concerns outlined in the companion letter issued with this SPA approval.

Enclosed is a copy of the following CS24 state plan pages and attachments to be incorporated within a separate section at the end of Iowa’s approved state plan:

CS24 Attachment 1 — Statement of use with respect to the alternative single streamlined paper application

e Attachment 2 — Statement of use with respect to the alternative single streamlined online application

This approval and the enclosures supercede the following sections of the current CHIP state plan:

e Section 4.3: Single Streamlined Application Screen and Enroll Process e Section 4.4: Renewals, Screening by Other Insurance Affordability Programs

The CMS appreciates the significant amount of work your staff dedicated to preparing this State Plan Amendment. Your title XXI project officer is Mr. Martin Burian. He is available to answer

Page 2 — Mr. Charles Palmer

questions concerning this amendment and other CHIP-related issues. Mr. Burian’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop: S2-01-16

7500 Security Blvd.

Baltimore, MD 21244-1850

Telephone: (410) 786-3246

Facsimile: (410) 786-5882

E-mail: Martin.Burian@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Mr. Burian and to Mr. James Scott, Associate Regional Administrator (ARA) in our Kansas City Office. Mr. Scott’s address is:

Mr. James Scott

Office of the Regional Administrator 601 E. 12" Street, Suite 235

Kansas City, MO 64106

If you have additional questions, please contact Linda Nablo, Director, Division of State Coverage Programs at (410) 786-5143.

We look forward to continuing to work with you and your staff.

Eliot Fishman Director Enclosure

ce: Mr. James Scott, ARA, CMS Region VII, Kansas City

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop: S2-26-12 Baltimore, Maryland 21244-1850

Children and Adults Health Programs Group

CENTERS FOR MEDICARE & MEDICAID SERVICES

CENTER FOR MEDICAID & CHIP SERVICES

MAR 2 6 2014

Charles M. Palmer, Director

Iowa Department of Human Services Hoover State Office Building

1305 East Walnut, 5" Floor

Des Moines, Iowa 50319-0119

RE: CS24 — Eligibility Process State Plan Amendment (SPA), IA-13-0021

Dear Mr. Palmer:

This letter is being sent as a companion to the Centers for Medicare & Medicaid Services (CMS) approval of state plan amendment (SPA) IA-13-0021, which was submitted to CMS on December 30, 2013. Our review of this submission included a review of the alternative single

streamlined paper and online applications developed by the state.

Until December 31, 2014, the state is using interim alternative single streamlined online and paper applications. By December 31, 2014, the state will implement revised applications to

reflect the following changes indicated below:

Alternative Single Streamlined Online Application:

Necessary changes:

Date by which changes will be completed:

The following questions will not appear on the online application

for health coverage only: e Questions regarding “Last Year’s Tax Return”

e ‘When did the new person join the household?” (unless the applicant is requesting retroactive coverage and indicated

that someone moved into or out of the household)

December 31, 2014

Necessary changes:

Date by which changes will be completed:

The following questions will not appear for household members

not seeking any benefits:

e The three non-MAGI screening questions related to

disability, blindness and long term care need Are you a resident of lowa? e All citizenship and immigration questions

December 31, 2014

Page 2 — Mr. Charles Palmer

All applicants will be given the option to consent to their tax data being checked at the time of renewal, for up to 5 years, or a lower number of years.

December 31, 2014

Only applicants who do not appear eligible for Medicaid and CHIP based on income attestation will be asked information about access to employer-sponsored coverage, beyond what is needed for Medicaid and CHIP.

December 31, 2014

Alternative Single Streamlined Paper Application:

The state will rephrase the question asking for amount of premium for the applicant’s lowest cost offer of employer-sponsored coverage so that it collects this premium amount for everyone with an offer, not just those employees offered wellness plans.

December 31, 2014

Please submit the revised alternative single streamlined online application to CMS for review no later than December 1, 2014, to ensure approval by December 31, 2014. We continue to be available to provide technical assistance. If you have any questions about your application, please contact Victoria Collins at Victoria.Collins@cms.hhs.gov or (410) 786-2167.

We look forward to continuing to work with you and your staff.

Sincerely,

Linda Nablo

Director, Division of State Coverage Programs

ce: Mr. James Scott, ARA, CMS Region 7, Kansas City

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility IA.0688.R00.00 - Oct 01, 2013 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Iowa State Funds: $ Federal Funds: $ Submitted By: Anna Ruggle Last Revision Date: Oct 15, 2014 Submit Date: Dec 30, 2013 Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST-YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. IA-14-0027 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing Non-Financial Eligibility Proposed Effective Date 10/01/2013 (mm/dd/yyyy) Federal Statute/Regulation Citation 2102(b)(3) & 2107(e)(1)(O) of the SSA and 42 CFR 457, subpart C Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Character Count:75 out of 2000 This SPA will contain the single application for Medicaid and CHIP in Iowa. Signature of State Agency Official Page 1 of 2 Children's Health Insurance Program Eligibility: CMS 179 10/30/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: CMS 179 10/30/2014 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01/pages/chp_00.jsp

cms CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

2102(b)(3) & 2107(e)(1)(O) of the SSA and 42 CFR 457, subpart C

The CHIP Agency meets all of the requirements of 42 CFR 457, subpart C for application processing, eligibility screening and enrollment.

Application Processing

Indicate which application the agency uses for individuals apply ing for coverage who may be eligible based on the applicable modified adjusted gross income standard:

oO The single, streamlined application developed by the Secretary in accordance with section 1413(b)(1)(A) of the Affordable Care Act.

An alternative single, stream lined application developed by the state and approved by the Secretary in accordance with section 1413(b)(1)(B) of the Affordable Care Act.

An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the (71 agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through such programs.

wl The agency's procedures permit an individual, or authorized person acting on behalf of the individual, to submit an application via the internet website described in CF R 457.340(a), by telephone, via mail, in person and other commonly available electronic means.

The agency accepts applications in the following other electronic means.

Other electronic means:

Name of method Description

Facsimile FAX

Screen and Enroll Process

The CHIP Agency has coordinated eligibility and enrollment screening procedures in place that are applied at time of initial re application, periodic redeterminations, and follow-up eligibility determinations. The procedures ensure that only targeted low- iv] income children are provided CHIP coverage and that enrollment is facilitated for applicants found to be potentially eligible for

other insurance affordability programs.

Procedures include:

MAR 2 6 2014 Effective Date: October 1, 2013

Page 1 of 2

SPA# IA-13-0021 Approval Date:

CHIP Eligibility

Screening of application to identify all individuals eligible or potentially eligible for CHIP or other insurance affordability a programs; and

al Income eligibility test, with calculation of household income consistent with 42 CFR 457.315 for individuals identified as potentially eligible for Medicaid or other insurance affordability programs based on household income; and

ia Screening process for individuals who may qualify for Medicaid on a basis other than having household income at or below the applicable MAGI standard, based on information in the single stream lined application.

The CHIP agency has entered into an arrangement with the Exchange to make eligibility determinations for advanced

premium tax credits in accordance with section 1943(b)(2) of the SSA. Yes

Redetermination Processing

wl Redeterm inations of eligibility for individuals whose financial eligibility is based on the applicable modified adjusted gross income standard are performed as follows, consistent with 42 CFR 457.343:

[M]_ Once every 12 months.

ia Without requiring information from the individual if able to do so based on reliable information contained in the individual's account or other more current information available to the agency.

If the agency cannot determine eligibility solely on the basis of the information available to it, or otherwise needs additional [i] information to complete the redetermination, it provides the individual with a pre-populated renewal form containing the information already available.

Screening by Other Insurance Affordability Programs

The CHIP Agency provides assurance that it has adopted procedures to accept and process electronic accounts of individuals

screened as potentially eligible for CHIP by other insurance affordability programs in accordance with the requirements of 42 CFR 457,348(b) and to determine eligibility in accordance with 42 CFR 457.340 in the same manner as if the application had been submitted directly to, and processed by the state.

The CHIP Agency elects the option to accept CHIP eligibility decisions made by the Exchange or other agencies administering

oO insurance affordability programs as provided in 42 CFR 457.348 and to furnish CHIP in accordance with requirem ents of 42 CFR 457.340 to the same extent and in the same manner as if the applicant had been determined by the state to be eligible for CHIP.

The CHIP Agency has entered into an agreement with agencies administering other insurance affordability programs to fulfill the ¥ requirements of 457.348(b) and will provide this agreement to the Secretary upon request.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Mary land 21244-1850.

SPA# IA-13-0021 Approval Date: MAR 2 6 2014

Effective Date: October 1, 2013 Page 2 of 2

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

C1 Paper Application

EX] Online Application

TRANSMITTAL NUMBER:

TA-13-0021

STATE:

Iowa

Through December 31, 2014, the state is using an interim alternative single streamlined application. After December 31, 2014, the state will use a revised alternative single streamlined application. The revised application will address the issues outlined in the CMS letter, which was issued with the approval of this state plan amendment, concerning the state’s application. The revised application will be incorporated by reference

into the state plan.

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

[xlPaper Application OOnline Application TRANSMITTAL NUMBER: STATE: IA-13-0021 Iowa

Through December 31, 2014, the state is using an interim alternative single streamlined application. After December 31, 2014, the state will use a revised alternative single streamlined application. The revised application will address the issues outlined in the CMS letter, which was issued with the approval of this state plan amendment, concerning the state’s application. The revised application will be incorporated by reference

into the state plan.

_____________________________________________________________________________

Table of Contents

State/Territory Name: Iowa

State Plan Amendment (SPA) #: IA-13-0022

This file contains the following documents in the order listed:

1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages

The complete title XXI state plan for Iowa consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: XXI state plans and amendments: http://medicaid.gov/chip/state-program-information/chipstate- program-information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop: S2-01-16 Baltimore, Maryland 21244-1850

Children and Adults Health Programs Group

CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

JUL 07 2014

Charles M. Palmer

Director

Iowa Department of Human Services Hoover State Office Building

1305 East Walnut, 5" Floor

Des Moines, IA 50319

Dear Mr. Palmer:

Tam pleased to inform you that the Centers for Medicare & Medicaid Services has approved your Children’s Health Insurance Program (CHIP) state plan amendment (SPA) number [A-13-0022, submitted on December 31, 2013, with additional information provided on July 3, 2014. This SPA relates to Modified Adjusted Gross Income (MAGI) Eligibility and has an effective date of

January 1, 2014.

The SPA number IA-13-0022 is approved to clarify the state’s non-financial eligibility policies on residency, citizenship, social security numbers, substitution of coverage, non-payment of

premiums, continuous eligibility and presumptive eligibility. Copies of the approved state plan pages are attached, and these approved pages supersede sections of Iowa’s current state plan as

detailed below:

New State Plan Page

Impact on Current State Plan Section

CS17: Non-Financial Eligibility — Residency

Section 4.1.5

CS18: Non-Financial Eligibility — Citizenship

Section 4.1.0; 4.1-LR; 4.1.1-LR

CS19: Non-Financial Eligibility — Social Security

Section 4.1.9.1

Premiums

Number

CS20: Non-Financial Eligibility — Substitution of | Section 4.4.4 Coverage

CS21: Non-Financial Eligibility - Non-Payment of | Section 8.7

CS27: General Eligibility — Continuous Eligibility

Section 4.1.8

for Children

CS28: General Eligibility - Presumptive Eligibility

Section 4.3.2

Your title XXI project officer is Mr. Martin Burian. He is available to answer questions concerning this amendment. Mr. Burian’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services

Page 2 — Mr. Charles M. Palmer

7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850

Telephone: (410) 786-3246

Facsimile: (410) 786-5882

E-mail: Martin.Burian@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Mr. Burian and to Mr. James-G. Scott, Associate Regional Administrator in our Kansas City Regional Office. Mr. Scott’s address is:

Centers for Medicare & Medicaid Services

Division of Medicaid and Children’s Health Operations Richard Bolling Federal Building

601 East 12 St, Room 355

Kansas City, MO 64103-2808

If you have additional questions, please contact Ms. Kelly Whitener, Director, Division of State

Coverage Programs, at (410) 786-0719. We look forward to continuing to work with you and your staff.

10t Fishman Director

Enclosures

Cc: James G. Scott, ARA, CMS Region VII

ccmMs CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

CS17

Separate INon-Fina

42 CFR 457.320

Residency

The CHIP Agency provides CHIP to otherwise eligible residents of the state, including residents who are absent from the state under certain conditions.

A child is considered to be a resident of the state under the following conditions:

iw A non-institutionalized child, if capable of indicating intent and who is emancipated or married, if the child is living in the state and: :

1. Intends to reside in the state, including without a fixed address. or 2. Has entered the state with a job commitment or seeking employment, whether or not currently employed. [] A non-institutionalized child not described above and a child who is not a ward of the state:

1, Residing in the state, with or without a fixed address, or

2. The state of residency of the parent or caretaker, in accordance with 42 CFR.435.403(h)(1). with whom the individual resides.

im An institutionalized child, who is not a ward of the state, if the state is the state of residence of the child's custodial parent or caretaker at the time of placement, or

[lM A child who is a ward of the state regardless of where the child lives, or

A child physically located in the state when there is a dispute with one or more states as to the child's actual state of a residence.

If the state covers pregnant women, a pregnant woman is considered to be a resident under the following conditions: [im] A non-institutionalized pregnant woman who is living in the state and: 1, Intends to reside in the state, including without a fixed address, or if incapable of indicating intent, is living in the state, or 2. Entered with a job commitment or seeking employment, whether or not currently employed.

im] An institutionalized.pregnant woman placed in an out-of-state-institution, as defined in 42 CFR 435.1010. including foster care homes, by an agency of the state, or

rl An institutionalized pregnant woman residing in an in-state-institution, as defined in 42 CFR 435.1010, whether or not the individual established residency in the state prior to entering the institution, or

ry A pregnant woman physically located in the state when there is a dispute with one or more states as to the pregnant woman's actual state of residence.

The state has in place related to the residency of children and pregnant women (if covered by the state):

SPA# IA-13-0022 Approval Date:, JUL 0 7 2014 Effective Date: January 1, 2014

Page 1 of 2

coms CHIP Eligibility

One or more interstate agreement(s). No

A policy related to individuals in the state only for educational purposes. No

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources. gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

SPA# IA-13-0022 Approval Date: JUL 07 2014

Effective Date: January 1, 2014

Page 2 of 2

coms CHIP Eligibility

OMB Control Number: 0938-1148 {xpiration date: 10/31/2014

CS18

Separate Child (Non-Financial Eli;

Sections 2105(c)(9) and 2107(e)( 1)(J) of the SSA and 42 CFR 457.320(b)(6), (c) and (d)

Citizenship

The CHIP Agency provides CHIP eligibility to otherwise eligible citizens and nationals of the United States and certain non-citizens. including the time period during which they are provided with reasonable opportunity to submit verification of their citizenship, national status or satisfactory immigration status.

[i] The CHIP Agency provides eligibility under the Plan to otherwise eligible individuals:

Who are citizens or nationals of the United States; or

Who are qualified non-citizens as defined in section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) (8 U.S.C. §1641), or whose eligibility is required by section 402(b) of PRWORA (8 U.S.C. §1612(b)) and is not prohibited by section 403 of PRWORA (8 U.S.C. §1613); or

Who have declared themselves to be citizens or nationals of the United States, or an individual having satisfactory immigration status, during a reasonable opportunity period pending verification of their citizenship, nationality, or satisfactory immigration status consistent with requirements of 1903(x), 1137(d), and 1902(ee) of the Act, and 42 CFR 435.406, 407, 956 and 457.380.

The reasonable opportunity period begins on and extends 90 days from the date the notice of reasonable opportunity is received by the individual.

The agency provides for an extension of the reasonable opportunity period if the individual is making a good faith effort

to resolve any inconsistencies or obtain any necessary documentation, or the agency needs more time to complete the Yes verification process.

The agency begins to furnish benefits to otherwise eligible individuals during the reasonable opportunity period on a date No earlier than the date the notice is received by the individual.

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible children up to age 19, lawfully residing Yes in the United States, as provided in Section 2107(e)(1)(J) of the SSA (Section 214 of CHIPRA 2009, P.L. 111-3). "

Otherwise eligible children means children meeting the eligibility requirements of targeted low-income children with the exception of non-citizen status.

The CHIP Agency provides assurance that lawfully residing children are also covered under the state's Medicaid program.

The CHIP Agency elects the option to provide CHIP coverage to otherwise eligible pregnant women, lawfully residing in the United States, as provided in Section 214 of CHIPRA 2009, P.L. 111-3. The state may not select this option unless the state

also elects to cover lawfully residing children. A state may not select this option unless the state also covers Targeted Low- No Income Pregnant Women.

rl] An individual is considered to be lawfully residing in the United States if he or she is lawfully present and meets state residency requirements.

[i] An individual is considered to be lawfully present in the United States if he or she is:

SPA# IA-13-0022 Approval Date: JUL 0 7 2014 Effective Date: January 1, 2014 Page 1 of 2

CccomMs. CHIP Eligibility

1. A qualified non-citizen as defined in 8 U.S.C. 1641(b) and (c);

2. A non-citizen in a valid nonimmigrant status, as defined in 8 U.S.C. 1101(a)(15) or otherwise under the immigration laws (as defined in 8 U.S.C. 1101(a)(17));

3. A non-citizen who has been paroled into the United States in accordance with 8 U.S.C.1182(d)(5) for less than 1 year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings;

4. A non-citizen who belongs to one of the following classes: (i) Granted temporary resident status in accordance with 8 U.S.C.1160 or 1255a, respectively;

(ii) Granted Temporary Protected Status (TPS) in accordance with 8 U.S.C. §1254a, and individuals with pending applications for TPS who have been granted employment authorization;

(iii) Granted employment authorization under 8 CFR 274a.12(c);

(iv) Family Unity beneficiaries in accordance with section 301 of Pub. L. 101-649, as amended;

(v) Under Deferred Enforced Departure (DED) in accordance with a decision made by the President; (vi) Granted Deferred Action status;

(vii) Granted an administrative stay of removal under 8 CFR 241;

(viii) Beneficiary of approved visa petition who has a pending application for adjustment of status;

5. [s an individual with a pending application for asylum under 8 U.S.C. 1158, or for withholding of removal under 8 U.S.C.123 I or under the Convention Against Torture, who:

(i) Has been granted employment authorization; or

(ii) Is under the age of 14 and has had an application pending for at least 180 days; 6. Has been granted withholding of removal under the Convention Against Torture; 7. Is a child who has a pending application for Special Immigrant Juvenile status as described in 8 U.S.C.1101(a)(27)(J); 8. Is lawfully present in American Samoa under the immigration laws of American Samoa; or

9. Is a victim of severe trafficking in persons, in accordance with the Victims of Trafficking and Violence Protection Act of 2000, Pub. L. 106-386, as amended (22 U.S.C. 7105(b)).

10. Exception: An individual with deferred action under the Department of Homeland Security's deferred action for the childhood arrivals process. as described in the Secretary of Homeland Security's June 15. 2012 memorandum, shall not be considered to be lawfully present with respect to any of the above categories in paragraphs (1) through (9) of this definition.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer. Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. JUL " 7 2014

SPA# IA-13-0022 Approval Date:, Effective Date: January 1, 2014

Page 2 of 2

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

CS19

42 CFR 457.340(b)

Social Security Number Asa condition of eligibility. the CHIP Agency must require individuals who have a social security number or are eligible for one as

determined by the Social Security Administration, to furnish their social security number, or numbers if they have more than one number.

The CHIP Agency requires individuals. as a condition of eligibility, to furnish their social security number(s). with the following exceptions:

Individuals refusing to obtain a social security number (SSN) because of well established religious objections, or Individuals who are not eligible for an SSN, or

Individuals who are issued an SSN only for a valid non-work purpose.

wl The CHIP Agency assists individuals, who are required to provide their SSN, to apply for or obtain an SSN from the Social Security Administration if the individual does not have or forgot their SSN.

[lM] The CHIP Agency informs individuals required to provide their SSN: By what statutory authority the number is solicited; and

How the state will use the SSN.

The CHIP Agency provides assurance that it will verify each SSN furnished by an applicant or beneficiary with the Social Security Administration, not deny or delay services to an otherwise eligible applicant pending issuance or verification of the individual's SSN by the Social Security Administration and that the state's utilization of the SSNs is consistent with sections 205

and 1137 of the Social Security Act and the Privacy Act of 1974.

The state may request non-applicant household members to voluntarily provide their SSN, if the state meets the requirements below.

The state requests non-applicant household members to voluntarily provide their 0 SSN.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05. Baltimore, Maryland 21244-1850.

JUL 07 2044

SPA# IA-13-0022 Approval Date: Effective Date: January 1, 2014

Page | of I

CMs. CHIP Eligibility

OMB Control Number: 0938-1148 ‘piration date: 10/31/2014

C820

Separate Child Non-Financial Eligil

Section 2102(b)(3)(C) of the SSA and 42 CFR 457.340(d)(3), 457.350(i), and 457.805

Substitution of Coverage

The CHIP Agency provides assurance that it has methods and policies in place to prevent the substitution of group health coverage or other commercial health insurance with public funded coverage. These policies include:

[im] Substitution of coverage prevention strategy:

Name of policy Description + Waiting period A one-month waiting period shall be imposed for a child who is subject to a monthly premium. xX

A waiting period during which an individual is ineligible due to having dropped group health coverage. How long is the waiting period? @ One month

C Two months

C 90 days C Other

[il] The state allows exemptions from the waiting period for the following reasons:

am The premium paid by the family for coverage of the child under the group health plan exceeded 5 percent of household income.

The child’s parent is determined eligible for advance payment of the premium tax credit for enrollment in a QHP [M] through the Marketplace because the ESI in which the family was enrolled is determined unaffordable in accordance with 26 CFR 1.36B—2(c)(3)(v).

[Mf] The cost of family coverage that includes the child exceeded 9.5 percent of the household income.

wy The employer stopped offering coverage of dependents (or any coverage) under an employer-sponsored health insurance plan.

ry A change in employment, including involuntary separation, resulted in the child’s loss of employer-sponsored insurance (other than through full payment of the premium by the parent under COBRA).

[@] The child has special health care needs.

[m] The child lost coverage due to the death or divorce of a parent.

Does the state allow other exemptions in addition to those listed above? | Yes

JUL 07 2014

SPA# 1A-13-0022 Approval Date: Effective Date: January 1, 2014 Page | of 3

coms CHIP Eligibility

Describe

+ Health insurance was provided through an individual plan.

The child's health insurance coverage was lost due to domestic violence.

+] x

The child's health insurance coverage was lost due to an involuntary loss of employment that qualified the parent for dependent coverage, including, but not limited to layoff, business closure, reduction in hours, or termination.

+

The child's health insurance coverage was lost due to utilization of the maximum lifetime coverage amount.

coverage under COBRA.

The child's health insurance coverage was lost due to a reason beyond the "| control of the parent, such as a serious illness of the parent. fire, flood. or “| natural disaster.

+ ; + The child's health insurance coverage was lost due to expiration of +

ye le |

+ The child is moving from Medicaid to CHIP. xX

rl Describe the processes the state employs to facilitate enrollment of CHIP-eligible children who have satisfied the waiting period.

Subsequent to state determining that a child is not subject to any of the exceptions to the waiting period. a family is sent a Notice of Action informing that their child is eligible for CHIP coverage effective one month from the date of application. The child is immediately enrolled in coverage one month from the date of application. and no additional action is required by the family.

Describe the processes the state employs to coordinate coverage of children subject to a waiting period with other [i] insurance affordability programs, including safeguards to prevent gaps in coverage for children transitioning from another insurance affordability program to CHIP after satisfying the waiting period.

Applications received by the state and subject to the one month waiting period are sent to the FFM via an electronic transfer to be evaluated for other Insurance Affordability Programs. The uotice to the family indicates that the application is being evaluated for other programs as well as the first eligible date of coverage under the hawk-i program. The child is automatically enrolled in hawk-i once the waiting period ends without any further action required from the client.

The state provides assurance that:

It does not require a new application or the submission of information already provided by the family immediately preceding the waiting period for the purpose of enrolling CHIP-eligible children who have satisfied a waiting period.

For children subject to the waiting period, it will promptly transfer each individual’s electronic account to the applicable insurance affordability program and notify such program of the date on which the waiting period ends for each individual.

(1 If the state covers pregnant women, the waiting period does not apply to pregnant women.

If the state elects to offer dental only supplemental coverage. the following assurances apply:

The other coverage exclusion does not apply to children who are otherwise eligible for dental only supplemental coverage as provided in section 2110(b)(5) of the SSA.

SPA# IA-13-0022 Approval Date: J UL 0 7 2014 Effective Date: January 1, 2014 Page 2 of 3

ccMs CHIP Eligibility

The waiting period does not apply to children eligible for dental only supplemental coverage.

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer. Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20131122

JUL 07 2014

SPA# IA-13-0022 Approval Date: Effective Date: January 1, 2014 Page 3 of 3

CHIP Eligibility

OMB Control Number: 0938-1148 piration date: 10/31/2014

Nee S21 42 CFR 457.570 Non-Payment of Premiums Does the state impose premiums or enrollment fees? Yes Can non-payment of premiums or enrollment fees result in loss of CHIP eligibility? Yes Does the state have a premium lock out period? Yes

Please describe the lock-out period:

hawk-i members who have outstanding premium payments at the time of application or renewal, must make payment of the premiums if they are applying within 90 days from the date of cancelation.

What is the length of the time premium lock-out period? Select a length of time:

C One month

C Two months

@ 90 days

C Other (not to exceed 90 days)

Are there exceptions to the required lock-out period? Yes

Individual's income decreased to a level where no premium is required or within Medicaid standards (1) Other financial hardship 1] Other

The state assures that:

It does not require the collection of past due premiums or enrollment fees as a condition of eligibility for enrollment once the lock-out period has expired; and

It provides enrollees with an opportunity for an impartial review to address disenrollment from the program in accordance with section 457.1130(a)(3); and

The child will be reenrolled in CHIP during the lock-out period upon payment of past due premiums or enrollment fees.

PRA Disclosure Statement

JUL 07 2014

SPA# IA-13-0022 Approval Date:, Effective Date: January 1, 2014 Page | of 2

coms. CHIP Eligibility

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS. 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore. Maryland 21244-1850.

V.20130709

SPA# IA-13-0022 JUL 0 7 2014

Approval Date: Effective Date: January 1, 2014 Page 2 of 2

CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

C827

2105(a)(4)(A) of the SSA and 42 CFR 457.342 and 435.926

‘The CHIP Agency may provide that children who have been determined eligible under the state plan shall remain eligible, regardless of

any changes in the family’s circumstances. during a continuous eligibility period up to 12 months, or until the time the child reaches an age specified by the state (not to exceed age 19), whichever is earlier.

The CHIP Agency elects to provide continuous eligibility to children under this provision. |Yes

@ For children up to age 19

C For children up to age

The continuous eligibility period begins on the effective date of the child's most recent determination or redetermination of eligibility, and ends:

[] Attheendofthe |12 | months continuous eligibility period.

Exceptions to the continuous eligibility period: [Ml The child attains the age specified by the state Agency or age 19. [B) The child or child's representative requests voluntary disenrollment.

[M] The child is no longer a resident of the state.

= The Agency determines that eligibility was erroneously granted at the most recent determination or renewal of eligibility because of Agency error or fraud, abuse, or perjury attributed to child or child's representative.

[mM] The child dies. [m] There is a failure to pay required premiums or enrollment fees on behalf of a child, as provided for in the state plan.

( Other

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of

the time estimate(s) or suggestions for improving this form, please write to: CMS, 7560 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130717

JUL 07 2014 SPA# IA-13-0022

Approval Date:, Effective Date: January 1, 2014

Page | of |

ccmMs CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

C828

42 CFR 457.355 and 435.1102, 2107(e)(1)(L) and 1920A of the SSA

The CHIP Agency covers children when determined presumptively eligible by a qualified entity. | Yes

[lm] Describe the population of children to whom presumptive eligibility applies:

‘The population of children to whom presumptive eligibility applies is all children under 302% of the federal poverty level.

[lM] Describe the duration of the presumptive eligibility period and any limitations:

Presumptive eligibility begins on the day the qualified entity determines that the child appears eligible and ends when one of the following occurs:

~ the last day of the next calendar month after the month of application, OR

- the day ongoing Medicaid is established, OR

- the day the hawk-i eligibility decision is made, OR

- the last day of the next calendar month, after the month of application, the Medicaid application is withdrawn.

[i] Describe the application process and eligibility determination factors used:

A person requesting presumptive eligibility for a child must complete a Presumptive Health Care Coverage for Children Application and submit it to a qualified entity. The qualified entity enters the information into the online application exactly as documented. The information is self-declared and is not yet verified.

Eligibility determination factors include the child must be under age 19, must be an Iowa resident, must be a citizen or qualified alien, live in a household with MAGI income less than 302% of the FPL, and not have received presumptive eligibility in the past 12 months from the month application is received by the qualified entity.

The CHIP Agency uses qualified entities, as defined in section 1920A, to determine eligibility presumptively for children. gency

A qualified entity is an entity that is determined by the agency to be capable of making presumptive eligibility determinations based on an individual’s household income and other requirements, and that meets at least one of the following requirements. Select the types of entities used to determine presumptive eligibility:

Furnishes health care items and services covered under the approved plan and is eligible to receive payments under the approved plan

x Is authorized to determine a child’s eligibility to participate in a Head Start program under the Head Start Act Is authorized to determine a child’s eligibility to receive child care services for which financial assistance bs is provided under the Child Care and Development Block Grant Act of 1990

SPA# IA-13-0022 Approval Date:. JUL 0 7 2014 Effective Date: January 1, 2014

Page 1 of 2

coms CHIP Eligibility

Is authorized to determine a child’s eligibility to receive assistance under the Special Supplemental Food Program for Women, Infants, and Children (WIC) under section 17 of the Child Nutrition Act of 1966

Ri

Is authorized to determine a child’s eligibility under the Medicaid state plan or for child health assistance under the Children’s Health Insurance Program (CHIP)

xX

Is an elementary or secondary school, as defined in section 14101 of the Elementary and Secondary Education Act of 1965 (20 U.S.C. 8801)

xX &

Is an elementary or secondary school operated or supported by the Bureau of Indian Affairs

Xl

Is a state or Tribal child support enforcement agency under title 1V-D of the Act

Is an organization that provides emergency food and shelter under a grant under the Stewart B. McKinney Homeless Assistance Act

xX

Is a state or Tribal office or entity involved in enrollment in the program under Medicaid, CHIP. or title IV-A of the Act

&l

Is an organization that determines eligibility for any assistance or benefits provided under any program of

BI public or assisted housing that receives Federal funds, including the program under section 8 or any other section of the United States Housing Act of 1937 (42 U.S.C. 1437) or under the Native American Housing Assistance and Self Determination Act of 1996 (25 U.S.C. 4101 ef seq.)

(] Any other entity the state so deems, as approved by the Secretary The CHIP Agency assures that it has communicated the requirements for qualified entities, at 1920A(b)(3)

of the Act, and provided adequate training to the entities and organizations involved. A copy of the training materials has been included.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

V.20130709

JUL 07 2014

SPA# IA-13-0022 Approval Date:, Effective Date: January 1, 2014 Page 2 of 2

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility IA.0721.R00.00 - Jan 01, 2014 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Iowa State Funds: $ Federal Funds: $ Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST- YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. IA-13-0022 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group Eligibility Processing  Non-Financial Eligibility Proposed Effective Date 01/01/2014 (mm/dd/yyyy) Federal Statute/Regulation Citation 42 CFR 457.320,Sections 2105(c)(9) and 2107(e)(1)(J) of the SSA and 42 CFR 457.320(b) Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Page 1 of 2 Children's Health Insurance Program Eligibility: Summary Page 09/14/2016 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01...

Submitted By: Anna Ruggle Last Revision Date: Jun 12, 2014 Submit Date: Dec 31, 2013 Character Count:55 out of 2000   The non-financial criteria for eligibility for the ACA. Signature of State Agency Official FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: Summary Page 09/14/2016 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01...

_____________________________________________________________________________ Table of Contents State/Territory Name: Iowa State Plan Amendment (SPA) #: IA-14-0021 This file contains the following documents in the order listed: 1) Approval Letter 2) SPA Summary Form 3) Approved SPA Pages The complete title XXI state plan for Iowa consists of the most recent state plan posted on Medicaid.gov under CHIP and State Plan Amendments. The link is provided below. The following approved templates are in addition to, or replace sections of the state’s posted current state plan. The attached approval letter(s) explain how these templates fit into that state plan. Link to state title XXI state plans and amendments: XXI state plans and amendments: http://medicaid.gov/chip/state-program-information/chipstate- program-information.html

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard, Mail Stop: S2-26-12

Children and Adults Health Programs Group

MAR 2 6 2014

Charles M. Palmer, Director

Iowa Department of Human Services Hoover State Office Building

1305 East Walnut, 5" Floor

Des Moines, IA 50319-0119

Dear Mr. Palmer:

I am pleased to inform you that the Centers for Medicare & Medicaid Services (CMS) has approved Iowa’s Children’s Health Insurance Program (CHIP) state plan amendment (SPA), IA- 13-0021, submitted on December, 30, 2013. This SPA incorporates the MAGI-based eligibility process requirements in accordance with the Affordable Care Act. The effective date of this SPA is October 1, 2013.

The state is using interim alternative single streamlined paper and online applications and by December 31, 2014, will implement revised alternative single streamlined paper and online applications that address CMS concerns outlined in the companion letter issued with this SPA approval.

Enclosed is a copy of the following CS24 state plan pages and attachments to be incorporated within a separate section at the end of Iowa’s approved state plan:

CS24 Attachment 1 — Statement of use with respect to the alternative single streamlined paper application

e Attachment 2 — Statement of use with respect to the alternative single streamlined online application

This approval and the enclosures supercede the following sections of the current CHIP state plan:

e Section 4.3: Single Streamlined Application Screen and Enroll Process e Section 4.4: Renewals, Screening by Other Insurance Affordability Programs

The CMS appreciates the significant amount of work your staff dedicated to preparing this State Plan Amendment. Your title XXI project officer is Mr. Martin Burian. He is available to answer

Page 2 — Mr. Charles Palmer

questions concerning this amendment and other CHIP-related issues. Mr. Burian’s contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid and CHIP Services Mail Stop: S2-01-16

7500 Security Blvd.

Baltimore, MD 21244-1850

Telephone: (410) 786-3246

Facsimile: (410) 786-5882

E-mail: Martin.Burian@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Mr. Burian and to Mr. James Scott, Associate Regional Administrator (ARA) in our Kansas City Office. Mr. Scott’s address is:

Mr. James Scott

Office of the Regional Administrator 601 E. 12" Street, Suite 235

Kansas City, MO 64106

If you have additional questions, please contact Linda Nablo, Director, Division of State Coverage Programs at (410) 786-5143.

We look forward to continuing to work with you and your staff.

Sincerely, Eliot Fishman Director Enclosure ce:

Mr. James Scott, ARA, CMS Region VII, Kansas City

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop: S2-26-12 Baltimore, Maryland 21244-1850

Children and Adults Health Programs Group

CENTERS FOR MEDICARE & MEDICAID SERVICES

CENTER FOR MEDICAID & CHIP SERVICES

MAR 2 6 2014

Charles M. Palmer, Director

Iowa Department of Human Services Hoover State Office Building

1305 East Walnut, 5" Floor

Des Moines, Iowa 50319-0119

RE: CS24 — Eligibility Process State Plan Amendment (SPA), IA-13-0021

Dear Mr. Palmer:

This letter is being sent as a companion to the Centers for Medicare & Medicaid Services (CMS) approval of state plan amendment (SPA) IA-13-0021, which was submitted to CMS on December 30, 2013. Our review of this submission included a review of the alternative single

streamlined paper and online applications developed by the state.

Until December 31, 2014, the state is using interim alternative single streamlined online and paper applications. By December 31, 2014, the state will implement revised applications to

reflect the following changes indicated below:

Alternative Single Streamlined Online Application:

Necessary changes:

Date by which changes will be completed:

The following questions will not appear on the online application

for health coverage only: e Questions regarding “Last Year’s Tax Return”

e ‘When did the new person join the household?” (unless the applicant is requesting retroactive coverage and indicated

that someone moved into or out of the household)

December 31, 2014

Necessary changes:

Date by which changes will be completed:

The following questions will not appear for household members

not seeking any benefits:

e The three non-MAGI screening questions related to

disability, blindness and long term care need Are you a resident of lowa? e All citizenship and immigration questions

December 31, 2014

Page 2 — Mr. Charles Palmer

All applicants will be given the option to consent to their tax data being checked at the time of renewal, for up to 5 years, or a lower number of years.

December 31, 2014

Only applicants who do not appear eligible for Medicaid and CHIP based on income attestation will be asked information about access to employer-sponsored coverage, beyond what is needed for Medicaid and CHIP.

December 31, 2014

Alternative Single Streamlined Paper Application:

The state will rephrase the question asking for amount of premium for the applicant’s lowest cost offer of employer-sponsored coverage so that it collects this premium amount for everyone with an offer, not just those employees offered wellness plans.

December 31, 2014

Please submit the revised alternative single streamlined online application to CMS for review no later than December 1, 2014, to ensure approval by December 31, 2014. We continue to be available to provide technical assistance. If you have any questions about your application, please contact Victoria Collins at Victoria.Collins@cms.hhs.gov or (410) 786-2167.

We look forward to continuing to work with you and your staff.

Sincerely,

Linda Nablo

Director, Division of State Coverage Programs

ce: Mr. James Scott, ARA, CMS Region 7, Kansas City

cms CHIP Eligibility

OMB Control Number: 0938-1148 Expiration date: 10/31/2014

2102(b)(3) & 2107(e)(1)(O) of the SSA and 42 CFR 457, subpart C

The CHIP Agency meets all of the requirements of 42 CFR 457, subpart C for application processing, eligibility screening and enrollment.

Application Processing

Indicate which application the agency uses for individuals apply ing for coverage who may be eligible based on the applicable modified adjusted gross income standard:

oO The single, streamlined application developed by the Secretary in accordance with section 1413(b)(1)(A) of the Affordable Care Act.

An alternative single, stream lined application developed by the state and approved by the Secretary in accordance with section 1413(b)(1)(B) of the Affordable Care Act.

An alternative application used to apply for multiple human service programs approved by the Secretary, provided that the (71 agency makes readily available the single or alternative application used only for insurance affordability programs to individuals seeking assistance only through such programs.

wl The agency's procedures permit an individual, or authorized person acting on behalf of the individual, to submit an application via the internet website described in CF R 457.340(a), by telephone, via mail, in person and other commonly available electronic means.

The agency accepts applications in the following other electronic means.

Other electronic means:

Name of method Description

Facsimile FAX

Screen and Enroll Process

The CHIP Agency has coordinated eligibility and enrollment screening procedures in place that are applied at time of initial re application, periodic redeterminations, and follow-up eligibility determinations. The procedures ensure that only targeted low- iv] income children are provided CHIP coverage and that enrollment is facilitated for applicants found to be potentially eligible for

other insurance affordability programs.

Procedures include:

MAR 2 6 2014 Effective Date: October 1, 2013

Page 1 of 2

SPA# IA-13-0021 Approval Date:

CHIP Eligibility

Screening of application to identify all individuals eligible or potentially eligible for CHIP or other insurance affordability a programs; and

al Income eligibility test, with calculation of household income consistent with 42 CFR 457.315 for individuals identified as potentially eligible for Medicaid or other insurance affordability programs based on household income; and

ia Screening process for individuals who may qualify for Medicaid on a basis other than having household income at or below the applicable MAGI standard, based on information in the single stream lined application.

The CHIP agency has entered into an arrangement with the Exchange to make eligibility determinations for advanced

premium tax credits in accordance with section 1943(b)(2) of the SSA. Yes

Redetermination Processing

wl Redeterm inations of eligibility for individuals whose financial eligibility is based on the applicable modified adjusted gross income standard are performed as follows, consistent with 42 CFR 457.343:

[M]_ Once every 12 months.

ia Without requiring information from the individual if able to do so based on reliable information contained in the individual's account or other more current information available to the agency.

If the agency cannot determine eligibility solely on the basis of the information available to it, or otherwise needs additional [i] information to complete the redetermination, it provides the individual with a pre-populated renewal form containing the information already available.

Screening by Other Insurance Affordability Programs

The CHIP Agency provides assurance that it has adopted procedures to accept and process electronic accounts of individuals

screened as potentially eligible for CHIP by other insurance affordability programs in accordance with the requirements of 42 CFR 457,348(b) and to determine eligibility in accordance with 42 CFR 457.340 in the same manner as if the application had been submitted directly to, and processed by the state.

The CHIP Agency elects the option to accept CHIP eligibility decisions made by the Exchange or other agencies administering

oO insurance affordability programs as provided in 42 CFR 457.348 and to furnish CHIP in accordance with requirem ents of 42 CFR 457.340 to the same extent and in the same manner as if the applicant had been determined by the state to be eligible for CHIP.

The CHIP Agency has entered into an agreement with agencies administering other insurance affordability programs to fulfill the ¥ requirements of 457.348(b) and will provide this agreement to the Secretary upon request.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Mary land 21244-1850.

SPA# IA-13-0021 Approval Date: MAR 2 6 2014

Effective Date: October 1, 2013 Page 2 of 2

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

C1 Paper Application

EX] Online Application

TRANSMITTAL NUMBER:

TA-13-0021

STATE:

Iowa

Through December 31, 2014, the state is using an interim alternative single streamlined application. After December 31, 2014, the state will use a revised alternative single streamlined application. The revised application will address the issues outlined in the CMS letter, which was issued with the approval of this state plan amendment, concerning the state’s application. The revised application will be incorporated by reference

into the state plan.

USE OF THE ALTERNATIVE SINGLE STREAMLINED APPLICATION

[xlPaper Application OOnline Application TRANSMITTAL NUMBER: STATE: IA-13-0021 Iowa

Through December 31, 2014, the state is using an interim alternative single streamlined application. After December 31, 2014, the state will use a revised alternative single streamlined application. The revised application will address the issues outlined in the CMS letter, which was issued with the approval of this state plan amendment, concerning the state’s application. The revised application will be incorporated by reference

into the state plan.

logged in as TONIABROWN(CMS CO Staff) read only mode application rev p01 Children's Health Insurance Program Eligibility IA.0688.R00.00 - Oct 01, 2013 Home Logout Finder Save Validate Print Help Control Panel General Information File Management Tribal Input Summary State/Territory name: Iowa State Funds: $ Federal Funds: $ Children's Health Insurance Program Eligibility: Summary Page Transmittal Number: Please enter the Transmittal Number (TN) in the format ST- YY-0000 where ST= the state abbreviation, YY = the last two digits of the submission year, and 0000 = a four digit number with leading zeros. The dashes must also be entered. IA-14-0027 Type of SPA: MAGI Eligibility & Methods XXI Medicaid Expansion Establish 2101(f) Group  Eligibility Processing Non-Financial Eligibility Proposed Effective Date 10/01/2013 (mm/dd/yyyy) Federal Statute/Regulation Citation 2102(b)(3) & 2107(e)(1)(O) of the SSA and 42 CFR 457, subpart C Federal Budget Impact This SPA has a budget impact. Total budget impact: Subject of Amendment Please provide a brief summary of SPA changes. Page 1 of 2 Children's Health Insurance Program Eligibility: Summary Page 09/14/2016 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01...

Submitted By: Anna Ruggle Last Revision Date: Oct 15, 2014 Submit Date: Dec 30, 2013 Character Count:75 out of 2000   This SPA will contain the single application for Medicaid and CHIP in Iowa. Signature of State Agency Official FAQs | Site Map | Contact | Medicaid.gov | CMS.gov Page 2 of 2 Children's Health Insurance Program Eligibility: Summary Page 09/14/2016 https://wms-mmdl.cdsvdc.com/MMDL/faces/protected/chp/p01...

_____________________________________________________________________________ Table of Contents State/Territory Name: Iowa State Plan Amendments (SPA) #: IA-15-0024 This file contains the following documents in the order listed: 1) Approval Letter 2) Final Approved State Plan

DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop S2-01-16 Baltimore, MD 21244-1850

CENTERS FOR MEDICARE & MEDICAID SERVICES CENTER FOR MEDICAID & CHIP SERVICES

Children and Adults Health Programs Group

AUG 2 0 2015

Mikki Stier, Director Division of Medical Services Iowa Medicaid Enterprise 100 Army Post Road

Des Moines, IA 50315

Dear Ms. Stier:

Your title XXI Children’s Health Insurance Program (CHIP) State plan amendment (SPA), IA-15-0024, submitted on June 4, 2015 has been approved. This SPA converts the current premium income bands to modified adjusted gross income levels (MAGI) as required by the Affordable Care Act. This CHIP SPA also updates the CHIP State plan to reflect previously approved MAGI eligibility SPAs. The effective date for this SPA is July 1, 2014.

Your title XXI project officer is Ms. Kristin Edwards. She is available to answer questions concerning this amendment and other CHIP-related issues. Ms. Edwards’ contact information is as follows:

Centers for Medicare & Medicaid Services Center for Medicaid & CHIP Services Mail Stop: S2-01-16

7500 Security Boulevard

Baltimore, MD 21244-1850

Telephone: (410) 786-5480

Facsimile: (410) 786-5882

E-mail: kristin.edwards@cms.hhs.gov

Official communications regarding program matters should be sent simultaneously to Ms. Edwards and to Mr. James Scott, Associate Regional Administrator (ARA) in our Kansas City Regional Office. Mr. Scott’s address is:

Centers for Medicare & Medicaid Services Division of Medicaid and Children’s Health Richard Bolling Federal Building

601 East 12" Street, Room 355

Kansas City, MO 64106-2808

If you have additional questions, please contact Mr. Manning Pellanda, Director, Division of State Coverage Programs at (410) 786-5143.

Page 2- Ms. Mikki Stier We look forward to continuing to work with you and your staff.

Sincerely,

Anne Marie Costello Acting Director

Enclosure

ce: Mr. James Scott, Associate Regional Administrator, Region VII

1 TEMPLATE FOR CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT CHILDREN’S HEALTH INSURANCE PROGRAM

(Required under 4901 of the Balanced Budget Act of 1997 (New section 2101(b)))

State/Territory: Iowa (Name of State/Territory)

As a condition for receipt of Federal funds under Title XXI of the Social Security Act, (42 CFR, 457.40(b)) Terry E. Branstad, Governor (Signature of Governor, or designee, of State/Territory, Date Signed)

submits the following Child Health Plan for the Children’s Health Insurance Program and hereby agrees to administer the program in accordance with the provisions of the approved Child Health Plan, the requirements of Title XXI and XIX of the Act (as appropriate) and all applicable Federal regulations and other official issuances of the Department.

The following State officials are responsible for program administration and financial oversight (42 CFR 457.40(c)):

Name: Charles. M. Palmer

Position/Title: Director, Iowa Department of Human Services Name: Mikki Stier, MSHA, FACHE

Position/Title: Medicaid Director

Name: Robert Schlueter

Position/Title: Chief, Bureau of Adult and Children's Medical Programs

*Disclosure. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0707. The time required to complete this information collection is estimated to average 80 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, write to: CMS, 7500 Security Blvd., Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

2 Introduction: Section 4901 of the Balanced Budget Act of 1997 (BBA), public law 105-33 amended the Social Security Act (the Act) by adding a new title XXI, the Children’s Health Insurance Program (CHIP). In February 2009, the Children’s Health Insurance Program Reauthorization Act (CHIPRA) renewed the program. The Patient Protection and Affordable Care Act of 2010 further modified the program.

This template outlines the information that must be included in the state plans and the state plan amendments (SPAs). It reflects the regulatory requirements at 42 CFR Part 457 as well as the previously approved SPA templates that accompanied guidance issued to States through State Health Official (SHO) letters. Where applicable, we indicate the SHO number and the date it was issued for your reference. The CHIP SPA template includes the following changes: • Combined the instruction document with the CHIP SPA template to have a single document. Any modifications to previous instructions are for clarification only and do not reflect new policy guidance. • Incorporated the previously issued guidance and templates (see the Key following the template for information on the newly added templates), including: • Prenatal care and associated health care services (SHO #02-004, issued November 12, 2002) • Coverage of pregnant women (CHIPRA #2, SHO # 09-006, issued May 11, 2009) • Tribal consultation requirements (ARRA #2, CHIPRA #3, issued May 28, 2009) • Dental and supplemental dental benefits (CHIPRA # 7, SHO # #09-012, issued October 7, 2009) • Premium assistance (CHIPRA # 13, SHO # 10-002, issued February 2, 2010) • Express lane eligibility (CHIPRA # 14, SHO # 10-003, issued February 4, 2010) • Lawfully Residing requirements (CHIPRA # 17, SHO # 10-006, issued July 1, 2010) • Moved sections 2.2 and 2.3 into section 5 to eliminate redundancies between sections 2 and 5. • Removed crowd-out language that had been added by the August 17 letter that later was repealed. The Centers for Medicare & Medicaid Services (CMS) is developing regulations to implement the CHIPRA requirements. When final regulations are published in the Federal Register, this template will be modified to reflect those rules and States will be required to submit SPAs illustrating compliance with the new regulations. States are not required to resubmit their State plans based on the updated template. However, States must use the updated template when submitting a State Plan Amendment.

Federal Requirements for Submission and Review of a Proposed SPA. (42 CFR Part 457 Subpart A) In order to be eligible for payment under this statute, each State must submit a Title XXI plan for approval by the Secretary that details how the State intends to use the funds and fulfill other requirements under the law and regulations at 42 CFR Part 457. A SPA is approved in 90 days unless the Secretary notifies the State in writing that the plan is disapproved or that specified additional information is needed. Unlike Medicaid SPAs, there is only one 90 day review period, or clock for CHIP SPAs, that may be stopped by a request for additional information and restarted after a complete response is received. More information on the SPA review process is found at 42 CFR 457 Subpart A.

3 When submitting a State plan amendment, states should redline the changes that are being made to the existing State plan and provide a “clean” copy including changes that are being made to the existing state plan.

The template includes the following sections: 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements- This section should describe how the State has designed their program. It also is the place in the template that a State updates to insert a short description and the proposed effective date of the SPA, and the proposed implementation date(s) if different from the effective date. (Section 2101); (42 CFR, 457.70) 2. General Background and Description of State Approach to Child Health Coverage and Coordination- This section should provide general information related to the special characteristics of each state’s program. The information should include the extent and manner to which children in the State currently have creditable health coverage, current State efforts to provide or obtain creditable health coverage for uninsured children and how the plan is designed to be coordinated with current health insurance, public health efforts, or other enrollment initiatives. This information provides a health insurance baseline in terms of the status of the children in a given State and the State programs currently in place. (Section 2103); (42 CFR 457.410(A)) 3. Methods of Delivery and Utilization Controls- This section requires a description that must include both proposed methods of delivery and proposed utilization control systems. This section should fully describe the delivery system of the Title XXI program including the proposed contracting standards, the proposed delivery systems and the plans for enrolling providers. (Section 2103); (42 CFR 457.410(A)) 4. Eligibility Standards and Methodology- The plan must include a description of the standards used to determine the eligibility of targeted low-income children for child health assistance under the plan. This section includes a list of potential eligibility standards the State can check off and provide a short description of how those standards will be applied. All eligibility standards must be consistent with the provisions of Title XXI and may not discriminate on the basis of diagnosis. In addition, if the standards vary within the state, the State should describe how they will be applied and under what circumstances they will be applied. In addition, this section provides information on income eligibility for Medicaid expansion programs (which are exempt from Section 4 of the State plan template) if applicable. (Section 2102(b)); (42 CFR 457.305 and 457.320) 5. Outreach- This section is designed for the State to fully explain its outreach activities. Outreach is defined in law as outreach to families of children likely to be eligible for child health assistance under the plan or under other public or private health coverage programs. The purpose is to inform these families of the availability of, and to assist them in enrolling their children in, such a program. (Section 2102(c)(1)); (42CFR, 457.90) 6. Coverage Requirements for Children’s Health Insurance- Regarding the required scope of health insurance coverage in a State plan, the child health assistance provided must consist of any of the four types of coverage outlined in Section 2103(a) (specifically, benchmark coverage; benchmark-equivalent coverage; existing comprehensive state-based coverage; and/or Secretary- approved coverage). In this section States identify the scope of coverage and benefits offered

4 under the plan including the categories under which that coverage is offered. The amount, scope, and duration of each offered service should be fully explained, as well as any corresponding limitations or exclusions. (Section 2103); (42 CFR 457.410(A)) 7. Quality and Appropriateness of Care- This section includes a description of the methods (including monitoring) to be used to assure the quality and appropriateness of care and to assure access to covered services. A variety of methods are available for State’s use in monitoring and evaluating the quality and appropriateness of care in its child health assistance program. The section lists some of the methods which states may consider using. In addition to methods, there are a variety of tools available for State adaptation and use with this program. The section lists some of these tools. States also have the option to choose who will conduct these activities. As an alternative to using staff of the State agency administering the program, states have the option to contract out with other organizations for this quality of care function. (Section 2107); (42 CFR 457.495) 8. Cost Sharing and Payment- This section addresses the requirement of a State child health plan to include a description of its proposed cost sharing for enrollees. Cost sharing is the amount (if any) of premiums, deductibles, coinsurance and other cost sharing imposed. The cost-sharing requirements provide protection for lower income children, ban cost sharing for preventive services, address the limitations on premiums and cost-sharing and address the treatment of pre- existing medical conditions. (Section 2103(e)); (42 CFR 457, Subpart E) 9. Strategic Objectives and Performance Goals and Plan Administration- The section addresses the strategic objectives, the performance goals, and the performance measures the State has established for providing child health assistance to targeted low income children under the plan for maximizing health benefits coverage for other low income children and children generally in the state. (Section 2107); (42 CFR 457.710) 10. Annual Reports and Evaluations- Section 2108(a) requires the State to assess the operation of the Children’s Health Insurance Program plan and submit to the Secretary an annual report which includes the progress made in reducing the number of uninsured low income children. The report is due by January 1, following the end of the Federal fiscal year and should cover that Federal Fiscal Year. In this section, states are asked to assure that they will comply with these requirements, indicated by checking the box. (Section 2108); (42 CFR 457.750) 11. Program Integrity- In this section, the State assures that services are provided in an effective and efficient manner through free and open competition or through basing rates on other public and private rates that are actuarially sound. (Sections 2101(a) and 2107(e); (42 CFR 457, subpart I) 12. Applicant and Enrollee Protections- This section addresses the review process for eligibility and enrollment matters, health services matters (i.e., grievances), and for states that use premium assistance a description of how it will assure that applicants and enrollees are given the opportunity at initial enrollment and at each redetermination of eligibility to obtain health benefits coverage other than through that group health plan. (Section 2101(a)); (42 CFR 457.1120)

Program Options. As mentioned above, the law allows States to expand coverage for children through a separate child health insurance program, through a Medicaid expansion program, or through a combination of these programs. These options are described further below:

5 • Option to Create a Separate Program- States may elect to establish a separate child health program that are in compliance with title XXI and applicable rules. These states must establish enrollment systems that are coordinated with Medicaid and other sources of health coverage for children and also must screen children during the application process to determine if they are eligible for Medicaid and, if they are, enroll these children promptly in Medicaid. • Option to Expand Medicaid- States may elect to expand coverage through Medicaid. This option for states would be available for children who do not qualify for Medicaid under State rules in effect as of March 31, 1997. Under this option, current Medicaid rules would apply.

Medicaid Expansion- CHIP SPA Requirements In order to expedite the SPA process, states choosing to expand coverage only through an expansion of Medicaid eligibility would be required to complete sections: • 1 (General Description) • 2 (General Background) They will also be required to complete the appropriate program sections, including: • 4 (Eligibility Standards and Methodology) • 5 (Outreach) • 9 (Strategic Objectives and Performance Goals and Plan Administration including the budget) • 10 (Annual Reports and Evaluations).

Medicaid Expansion- Medicaid SPA Requirements States expanding through Medicaid-only will also be required to submit a Medicaid State Plan Amendment to modify their Title XIX State plans. These states may complete the first check-off and indicate that the description of the requirements for these sections are incorporated by reference through their State Medicaid plans for sections: • 3 (Methods of Delivery and Utilization Controls) • 4 (Eligibility Standards and Methodology) • 6 (Coverage Requirements for Children’s Health Insurance) • 7 (Quality and Appropriateness of Care) • 8 (Cost Sharing and Payment) • 11 (Program Integrity) • 12 (Applicant and Enrollee Protections)

• Combination of Options- CHIP allows states to elect to use a combination of the Medicaid program and a separate child health program to increase health coverage for children. For example, a State may cover optional targeted-low income children in families with incomes of up to 133 percent of poverty through Medicaid and a targeted group of children above that level through a separate child health program. For the children the State chooses to cover under an expansion of Medicaid, the description provided under “Option to Expand Medicaid” would apply. Similarly, for children the State chooses to cover under a separate program, the provisions outlined above in “Option to Create a Separate Program” would apply. States wishing to use a combination of approaches will be

6 required to complete the Title XXI State plan and the necessary State plan amendment under Title XIX.

Proposed State plan amendments should be submitted electronically and one signed hard copy to the Centers for Medicare & Medicaid Services at the following address: Name of Project Officer Centers for Medicare & Medicaid Services 7500 Security Blvd Baltimore, Maryland 21244 Attn: Children and Adults Health Programs Group Center for Medicaid and CHIP Services Mail Stop - S2-01-16

7

Section 1. General Description and Purpose of the Children’s Health Insurance Plans and the Requirements

1.1. The state will use funds provided under Title XXI primarily for (Check appropriate box) (Section 2101)(a)(1)); (42 CFR 457.70):

Guidance: Check below if child health assistance shall be provided primarily through the development of a separate program that meets the requirements of Section 2101, which details coverage requirements and the other applicable requirements of Title XXI.

1.1.1. Obtaining coverage that meets the requirements for a separate child health program (Sections 2101(a)(1) and 2103); OR

Guidance: Check below if child health assistance shall be provided primarily through providing expanded eligibility under the State’s Medicaid program (Title XIX). Note that if this is selected the State must also submit a corresponding Medicaid SPA to CMS for review and approval. 1.1.2. Providing expanded benefits under the State’s Medicaid plan (Title XIX) (Section 2101(a)(2)); OR

Guidance: Check below if child health assistance shall be provided through a combination of both 1.1.1. and 1.1.2. (Coverage that meets the requirements of Title XXI, in conjunction with an expansion in the State’s Medicaid program). Note that if this is selected the state must also submit a corresponding Medicaid state plan amendment to CMS for review and approval. 1.1.3. A combination of both of the above. (Section 2101(a)(2))

Medicaid Expansion (M-CHIP) Effective July 1, 1998 • Children ages 15 through 18 in families with income between 37 percent and 100 percent of Federal Poverty Level (FPL). These are the "Waxman" children that are being phased-in to Medicaid as a mandatory coverage group. Beginning October 1, 2002, all of these children will be covered under Medicaid. • Children ages 6 through 18 in families with income that is equal to or less than 133 percent of FPL.

Effective July 1, 2000 Infants, up to one year of age, in families with income between 185 percent and 200 percent of FPL.

Effective July 1, 2009 When determining eligibility for infants, up to one year of age, all income between 185 percent and 300 percent of FPL shall be disregarded.

The State has implemented systems changes that allow for identification of children eligible for

8 Medicaid via CHIP so they can be reported separately from children eligible for Medicaid via the 1902(r)(2) Medicaid State Plan Amendment. This will allow CHIP eligible children (optional targeted low-income children) to be reported and claimed at the enhanced rate and other newly eligible children to be reported and claimed at the State's standard FMAP. Children eligible for Medicaid as a result of the expansion receive health care services through the same delivery systems that operate in the Medicaid program.

Separate Program: Healthy And Well Kids In Iowa (hawk-i) Program (S-CHIP) The Healthy And Well Kids in Iowa (hawk-i) program covers targeted low-income children up to age 19 in families who income does not exceed 200 percent of the FPL. Effective January 1, 1999, the State implemented the hawk-i program for targeted low-income children up to age 19 in families who income was at or below 185% of the Federal Poverty Level (FPL). The State expanded coverage to 200% of the FPL effective July 1, 2000. Effective July 1, 2009, when determining eligibility, all income between 200 percent and 300 percent of the FPL shall be disregarded. The hawk-i program has several components and is designed to encompass a variety of entry points into the program. The delivery of services follows a private sector commercial insurance model. Iowa Department of Human Services: The Department of Human Services (DHS) has been designated as the State agency to administer the hawk-i program. hawk-i Board. The Iowa General Assembly authorized the creation of the hawk-i Board to provide direction to the Department of Human Services and to establish policy for the program. The hawk-i Board is made up of eleven members: • Director of the Iowa Department of Public Health or their designee • Director of the Iowa Department of Education or their designee • Commissioner of the Iowa Division of Insurance or their designee • Four Governor-appointed public members • Four ex-officio legislators (2 Senate/2 House of Representatives)

Third Party Administrator: The Department of Human Services has contracted with a third party administrator to provide, at a minimum, the following services: • Distribute applications • Determine eligibility • Screen for Medicaid eligibility and coordinate with co-located Medicaid eligibility workers. • Calculate, bill, and collect cost sharing. • Assist the family in selecting a health plan and enrolling the child in the selected plan. • Provide DHS with demographic, statistical, and encounter data for federal reporting and other reporting requirements.

Advisory Committees: Two advisory committees have been established to provide input to the hawk-i Board. The Clinical Advisory Committee is made up of health care professionals who advise the hawk-i Board on issues around benefits, access, and quality. The Children With Special Health Care Needs Advisory Committee is made up of health care professionals and advocates who advise the hawk-i Board on health care issues faced by children with special needs and make recommendations on how to address those needs.

9 • Health and Dental Plans: The Department of Human Services contracts with health and dental plans licensed by the Division of Insurance within the Department of Commerce to provide health and dental care coverage to eligible children under the hawk-i program. • The University of Iowa Public Policy Center: The Department of Human Services contracts with the University of Iowa Public Policy Center to conduct analysis of the functional health assessment and analysis of the encounter data. Effective July 1, 2005, the Department of Human Services will contract with the Telligen (formerly Iowa Foundation for Medical Care) to conduct the analysis of the functional health assessment and analysis of the encounter data.

1.1-DS

The State will provide dental-only supplemental coverage. Only States operating a separate CHIP program are eligible for this option. States choosing this option must also complete sections 4.1-DS, 4.2-DS, 6.2-DS, 8.2-DS, and 9.10 of this SPA template. (Section 2110(b)(5))

1.2.

Check to provide an assurance that expenditures for child health assistance will not be claimed prior to the time that the State has legislative authority to operate the State plan or plan amendment as approved by CMS. (42 CFR 457.40(d))

1.3.

Check to provide an assurance that the State complies with all applicable civil rights requirements, including title VI of the Civil Rights Act of 1964, title II of the Americans with Disabilities Act of 1990, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, 45 CFR part 80, part 84, and part 91, and 28 CFR part 35. (42CFR 457.130)

Guidance: The effective date as specified below is defined as the date on which the State begins to incur costs to implement its State plan or amendment. (42 CFR 457.65) The implementation date is defined as the date the State begins to provide services; or, the date on which the State puts into practice the new policy described in the State plan or amendment. For example, in a State that has increased eligibility, this is the date on which the State begins to provide coverage to enrollees (and not the date the State begins outreach or accepting applications).

1.4. Provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this SPA (42 CFR 457.65). A SPA may only have one effective date, but provisions within the SPA may have different implementation dates that must be after the effective date.

Original Plan Effective Date: July 1,1998

Implementation Date: July 1, 1998

SPA # 18 Modified Adjusted Gross Income (MAGI) Eligibility and Methods

10 (Attachment 18) SPA #19 MAGI Medicaid Expansion Income Standards (Attachment 19) SPA #20 Establish 2101f Group (Attachment 20) SPA #21 MAGI Eligibility Process (Attachment 21) SPA #22 Non-Financial Eligibility (Attachment 22) SPA #23 Use of Health Service Initiatives to help fund the Iowa Poison Control Center

SPA # IA -15-0024 Purpose of SPA: Updating federal poverty levels that require a premium to the new Modified Adjusted Gross Income (MAGI).

Proposed effective date: July 1, 2014

Proposed implementation date: July 1, 2014 Superseding Pages of MAGI CHIP State Plan Material State: Iowa Transmittal Number SPA Group PDF # Description Superseded Plan Section(s) IA-13-0018

Effective/ Implementation Date: January 1, 2014 MAGI Eligibility & Methods CS7

CS12

CS15 Eligibility – Targeted Low Income Children

Eligibility- Supplemental Dental Only

MAGI-Based Income Methodologies Supersedes the current sections Geographic Area 4.1.1; Age 4.1.2; and Income 4.1.3

Supersedes the current Section 4.1-DS

Incorporate within a separate subsection under section 4.3

IA-13-0019

Effective/ Implementation Date: January 1, 2014 XXI Medicaid Expansion CS3 Eligibility for Medicaid Expansion Program Supersedes the current Medicaid expansion section 4.0 IA-13-0020

Effective/ Implementation Date: January 1, 2014 Establish 2101(f) Group CS14 Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards Incorporate within a separate subsection under section 4.1 IA-13-0021

Effective/ Implementation Eligibility Processing CS24 Eligibility Process Supersedes the current sections 4.3 and 4.4

11 Transmittal Number SPA Group PDF # Description Superseded Plan Section(s) Date: October 1, 2013 IA-13-0022

Effective/ Implementation Date: January 1, 2014 Non- Financial Eligibility

CS17

CS18

CS19

CS20

CS21

CS27

CS28 Residency

Citizenship

Social Security Number

Substitution of Coverage

Non-Payment of Premiums

Continuous Eligibility

Presumptive Eligibility for Children Supersedes the current section 4.1.5

Supersedes the current sections 4.1.0; 4.1.1-LR; 4.1.1-LR

Supersedes the current section 4.1.9.1

Supersedes the current section 4.4.4

Supersedes the current section 8.7

Supersedes the current section 4.1.8

Supersedes the current section 4.3.2

1.4- TC Tribal Consultation (Section 2107(e)(1)(C)) Describe the consultation process that occurred specifically for the development and submission of this State Plan Amendment, when it occurred and who was involved. No comments were received. TN No: Approval Date Effective Date

Section 2. General Background and Description of Approach to Children’s Health Insurance Coverage and Coordination

Guidance: The demographic information requested in 2.1. can be used for State planning and will be used strictly for informational purposes. THESE NUMBERS WILL NOT BE USED AS A BASIS FOR THE ALLOTMENT.

Factors that the State may consider in the provision of this information are age breakouts, income brackets, definitions of insurability, and geographic location, as well as race and ethnicity. The State should describe its information sources and the assumptions it uses for the development of its description. • Population

12 • Number of uninsured • Race demographics • Age Demographics • Info per region/Geographic information

2.1. Describe the extent to which, and manner in which, children in the State (including targeted low-income children and other groups of children specified) identified , by income level and other relevant factors, such as race, ethnicity and geographic location, currently have creditable health coverage (as defined in 42 CFR 457.10). To the extent feasible, distinguish between creditable coverage under public health insurance programs and public-private partnerships (See Section 10 for annual report requirements). (Section 2102(a)(1)); (42 CFR 457.80(a))

Historically, Iowa is a rural, agricultural state. However, recently there has been a shift in population from rural areas to urban centers. New estimates from the U.S. Census Bureau show that population growth in Iowa during the 2000's is confined to two areas: in and around Des Moines, and in theDavenport area . At the same time, 45 of Iowa's 99 counties are losing population. Data from 2010 suggests that 61percent of Iowans live inside a metropolitan area.

According to the 2010 U.S. Census, Iowa has a population of 3,046,355 with 26.9% (819,469) being children ages 19 and younger. The Census reports show 12.8% of Iowa's population or 389,933people living below poverty. In general, the highest levels of poverty are in the southern counties along the Missouri border.

While approximately 2,747,818 ((88.7%) of Iowa's population are white and 61,423 (4.1%) are black, Iowa is experiencing an ever-emerging diverse population. For Iowa's children ages 19 years and younger, the percentages of different races varies from the total population. The children are 80% white, 4.1% black or African American, 0.3% American Indian or Alaska Native, 2% are of other race and 3.4% are two or more races. There are63,207Hispanic children (can be of any race) in Iowa.

Additionally, Iowa is becoming home to more and more refugees from all areas of the world. Most recently, Iowa has had significant numbers of Sudanese and Bosnians settle in some of the larger urban centers of the State.

Estimate Number of Refugees and Amerasians in Iowa Region of Origin Number Who Originally Settled in Iowa Africa Sudanese 1,716 All other ethnicities 2,547

Near East

Iraqi 594 All Others 128

13 Former Soviet Union All ethnicities 220

Eastern Europe

Bosnian 7,915 Kosovar 191 All other ethnicities 117

Southeast Asia Vietnamese 1746 Tai Dam 11 Lowland Lao 115 Cambodian/Khmer 17 Hmong 26

Latin America/Caribbean

Haitian6 All other ethnicities 40

TOTAL 15,389

The Mesquaki Tribe is the only Federally recognized Native American Tribe in Iowa. It is a subset of the Sac and Fox of the Mississippi and Iowa Tribe and currently has 1,349 enrolled members. The improving economic conditions on the Mesquaki Settlement, primarily due to casino revenue, have resulted in a significant growth trend and 87% birth rate increase since 2010. According to the 2010 U.S. Census, 14,043 people identified themselves as Native American or Alaska Native. Of this number 39.6% are 19 years of age or younger.

The only public health insurance program generally available in Iowa is Medicaid. In February 2013, there were256,506children receiving coverage through the Medicaid program.

The Iowa Caring Program for Children, a primarily privately funded, Wellmark (Blue Cross Blue Shield of Iowa and South Dakota) sponsored program, covered about 3,000 children below 133% of FPL. This program covered uninsured children who did not qualify for Medicaid. With the expansion of Medicaid and implementation of the hawk-i program, the Caring Program ceased their program operations on July 1, 1999.

Guidance: Section 2.2 allows states to request to use the funds available under the 10 percent limit on administrative expenditures in order to fund services not otherwise allowable. The health services initiatives must meet the requirements of 42 CFR 457.10.

2.2. Health Services Initiatives- Describe if the State will use the health services initiative option as allowed at 42 CFR 457.10. If so, describe what services or programs the State is proposing to cover with administrative funds, including the cost of each program, and

14 how it is currently funded (if applicable), also update the budget accordingly. (Section 2105(a)(1)(D)(ii)); (42 CFR 457.10)

The State will use the health service initiatve option for those children found presumptively eligible for Medicaid who are later found to be hawk-i eligible. The health services initiatives will only be used for those services covered under Medicaid that are not covered under CHIP (hawk-i).

Iowa will use the health service initiative option allowed at 42 CFR 457.10 to support the Iowa Poison Control Center (IPCC). Poison treatment advice and prevention will be supported. Poison treatement advice through the IPCC will be supported using CHIP funds available under the 10 percent federal administrative expenditures cap. IPCC will not supplant or match CHIP HSI Federal funds with other Federal funds, nor allow Federal funds to supplant or match CHIP Federal Funds.

The Iowa Poison Control Center (IPCC) provides immediate access to expert treatment advice and assistance over the telephone in case of exposure to poisonous or hazardous substances. A single toll- free telephone number allows for rapid and direct access to highly specialized care for all Iowans including demographic populations that are typically underserved or lack access to high-quality health care, such as uninsured, low-income, immigrant families and individuals living in rural areas. Services are available 24 hours a day, seven days a week at no direct cost to the people who call. Translators are available in 150 languages through the language line.

The IPCC is contacted for all kinds of poisonings and overdoses affecting people of all ages: household products, medicines, pesticides, plants and mushrooms, bites and stings, food poisoning, and fumes. Public education is another crucial function of the IPCC and serves the dual role of promoting poison prevention behaviors and delivering outreach messages meant to foster awareness and utilization of PCC services. IPCC is staffed by nurses, pharmacists and physicians and other poison information providers who are specially trained in toxicology.

Nearly 26,000 poisoning exposure calls are received annually by IPCC (25,819 in CY 2013). Sixty- three percent involve a child under the age of 19. In addition to calls regarding exposures, the IPCC receives between 15,000-20,000 calls each year for poison or drug information. These calls are considered preventive.

More than 80% of the cases involving children under age 19 are managed entirely at home with telephone guidance from the IPCC avoiding unnecessary and costly emergency department visits and ambulance runs. An estimated 46% of callers are covered by Medicaid which saves the Iowa’s Medicaid program $5.7 million annually. The IPCC estimates the number of children on the Medicaid program or the Healthy and Well Kids in Iowa (hawk-i) program by conducting continuous randomized satisfaction surveys of callers in which it is also determined what type of health insurance they have. This percentage is significantly higher than Iowa’s total Medicaid and CHIP enrollment due to a combination of enhanced IPCC partnerships and targeted community-based outreach strategies for reaching low-income families. Increased awareness of IPCC services will help improve access to uninsured, low-income children and reduce unnecessary ER visits saving the federal and state

15 governments millions of dollars.

The IPCC has a long history of working closely with Head Start, Community Health Centers, WIC programs and physician clinics to reach the eligible population. Materials are also distributed through hospitals, health fairs, community and church groups, SAFE Kids coalitions, PTAs, school nurses, and classes for babysitters and new parents. Over 100,000 poison prevention materials are distributed each year throughout Iowa including brochures, phone stickers, magnets, posters, teacher packets, videos and other pieces. Culturally and linguistically appropriate learning materials are available in English, Spanish and Vietnamese. Newspaper, television, radio, IPCC website and social media also assist in communicating vital information.

A realistic and conservative study performed by the IPCC in 2013 showed that for every $1 invested in the poison center, $16.6 are saved in health care costs (Return on Investment of 16.6 to 1). An article published in the Journal of Medical Toxicology in 2008 stated that the ROI for the poison center that published the article was 36 to 1. If the IPCC applied the same methodology used in the 2008 article to our 2013 data, the IPCC’s ROI would increase to 53:1. A 2012 report by the independent Lewin Group determined that the return on investment for the Federal government alone is substantial, billions of dollars each year, due to reduced Medicare, Medicaid and SCHIP costs.

The IPCC is an independent, not-for-profit 501(c)(3) organization. In recognition of its high quality, the IPCC is accredited by the American Association of Poison Control Centers. The center has been historically reliant on a tenuous patchwork of funding made up of primarily state and federal grants and support from sponsoring organizations UnityPoint Health and University of Iowa Hospitals and Clinics. Available funds within this patchwork have not kept pace with lean current operations and, in fact, have been cut substantially in recent years. In 2013, the IPCC launched a hospital subscription program which now comprises 25% of its total operating revenues. The IPCC still faces a significant budget deficit due to expiring grants and discontinuation of open-ended sponsor support. IPCC’s current shortfall includes a funding gap of over $600,000 and faces closure without CHIP funding.

IPCC has been an outstanding example of how a public-private partnership can work in the state. CHIP funding will allow this organization to continue its strong track record of providing the residents of the State of Iowa access to valuable, cost-effective, and life-saving services.

Iowa will only utilize administrative cap money to help fund the IPCC through the Iowa Department of Public Health (IDPH). No federal funds will be claimed for HSI activities that took place before the effective date of the SPA or prior to CHIP funds being incurred for approved costs. These funds will be used to help offset the cost for treatment of low income children. A statement of expenditures, which include both the state share of expenses paid for by the Department of Public Health and the federal share of funds to be passed through the Department of Human Services (DHS), will be submitted to DHS to request reimbursement. The funds will be drawn from the Payment Management System and deposited into DHS accounts. These funds will then be transferred internally to the Department of Public Health as a reimbursement of the federal share of expenses. IDPH is the entity that is authorized by the Iowa Legislature to receive state funds for the IPCC. IDPH and IPCC will not supplant or match CHIP federal funds with other federal funds, no allow other federal funds to supplant or match CHIP

16 federal funds.

2.3-TC Tribal Consultation Requirements- (Sections 1902(a)(73) and 2107(e)(1)(C)); (ARRA #2, CHIPRA #3, issued May 28, 2009) Section 1902(a)(73) of the Social Security Act (the Act) requires a State in which one or more Indian Health Programs or Urban Indian Organizations furnish health care services to establish a process for the State Medicaid agency to seek advice on a regular, ongoing basis from designees of Indian health programs, whether operated by the Indian Health Service (IHS), Tribes or Tribal organizations under the Indian Self-Determination and Education Assistance Act (ISDEAA), or Urban Indian Organizations under the Indian Health Care Improvement Act (IHCIA). Section 2107(e)(1)(C) of the Act was also amended to apply these requirements to the Children’s Health Insurance Program (CHIP). Consultation is required concerning Medicaid and CHIP matters having a direct impact on Indian health programs and Urban Indian organizations.

Describe the process the State uses to seek advice on a regular, ongoing basis from federally-recognized tribes, Indian Health Programs and Urban Indian Organizations on matters related to Medicaid and CHIP programs and for consultation on State Plan Amendments, waiver proposals, waiver extensions, waiver amendments, waiver renewals and proposals for demonstration projects prior to submission to CMS. Include information about the frequency, inclusiveness and process for seeking such advice.

The State using the same process as Iowa Medicaid consulted with the Indian tribes and organizations regarding use of health service initiatives to help fund the Iowa Posion Control Center. The State received no comments. .

Section 3. Methods of Delivery and Utilization Controls

Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan, and continue on to Section 4. Guidance: In Section 3.1., discussion may include, but is not limited to: contracts with managed health care plans (including fully and partially capitated plans); contracts with indemnity health insurance plans; and other arrangements for health care delivery. The State should describe any variations based upon geography, as well as the State methods for establishing and defining the delivery systems.

Should the State choose to cover unborn children under the Title XXI State plan, the State must describe how services are paid. For example, some states make a global payment for all unborn children while other states pay for services on fee-for-services basis. The State’s payment mechanism and delivery mechanism should be briefly described here.

Section 2103(f)(3) of the Act, as amended by section 403 of CHIPRA, requires separate

17 or combination CHIP programs that operate a managed care delivery system to apply several provisions of section 1932 of the Act in the same manner as these provisions apply under title XIX of the Act. Specific provisions include: section 1932(a)(4), Process for Enrollment and Termination and Change of Enrollment; section 1932(a)(5), Provision of Information; section 1932(b), Beneficiary Protections; section 1932(c), Quality Assurance Standards; section 1932(d), Protections Against Fraud and Abuse; and section 1932(e), Sanctions for Noncompliance. If the State CHIP program operates a managed care delivery system, provide an assurance that the State CHIP managed care contract(s) complies with the relevant sections of section 1932 of the Act. States must submit the managed care contract(s) to the CMS Regional Office servicing them for review and approval.

In addition, states may use up to 10 percent of actual or estimated Federal expenditures for targeted low-income children to fund other forms of child health assistance, including contracts with providers for a limited range of direct services; other health services initiatives to improve children’s health; outreach expenditures; and administrative costs (See 2105(c)(2)(A)). Describe which, if any, of these methods will be used.

Examples of the above may include, but are not limited to: direct contracting with school-based health services; direct contracting to provide enabling services; contracts with health centers receiving funds under section 330 of the Public Health Service Act; contracts with hospitals such as those that receive disproportionate share payment adjustments under section 1886(d)(5)(F) or 1923 of the Act; contracts with other hospitals; and contracts with public health clinics receiving Title V funding. If applicable, address how the new arrangements under Title XXI will work with existing service delivery methods, such as regional networks for chronic illness and disability; neonatal care units, or early-intervention programs for at-risk infants, in the delivery and utilization of services. (42CFR 457.490(a))

3.1. Delivery Standards Describe the methods of delivery of the child health assistance using Title XXI funds to targeted low-income children. Include a description of the choice of financing and the methods for assuring delivery of the insurance products and delivery of health care services covered by such products to the enrollees, including any variations. (Section 2102)(a)(4) (42CFR 457.490(a))

Healthy And Well Kids in Iowa (hawk-i) Program The State has entered into contractual agreements with commercial insurers to provide a benchmark equivalent benefit package to enrollees in the hawk-i program. The insurer will provide the enrollee with a health plan card identifying them as an enrollee in that health plan. The enrollee will have a primary care physician if they are in a managed care plan.

Both indemnity and managed care plans are allowed to participate in the program. The goal is to allow choice among plans so that enrollees can select the health plan from which they want to receive coverage. Both indemnity and managed care plans receive a monthly capitation payment for each hawk- i enrollee in the plan. The State contracts with indemnity plans only in those counties where the State

18 does not have a contract with a managed care plan. If the State enters into a contract with a managed care plan in a county where the State currently has a contract with an indemnity plan, the hawk-i enrollees of the indemnity plan shall remain enrolled with the indemnity plan until the expiration of the twelve-month enrollment. All enrollees eligible for the hawk-i program after the execution of the contract with the managed care plan shall be enrolled with the managed care plan.

Effective July 1, 2003, the Iowa legislature passed legislation that allows dental only carriers to participate in the hawk-i program. Effective July 1, 2009, hawk-i dental services are provided through a separate dental plan, Delta Dental of Iowa. Participating health plans are no longer offering dental coverage.

A child shall remain enrolled in a health and dental plan for a twelve-month period unless: • a request for disenrollment from the plan is made at any time for cause; • a request for disenrollment from the plan is made without cause during the 90 days following the date of initial enrollment or when the third party administrator sends the notice of enrollment to the enrollee whichever is later; • there is a substantial change in the provider network of the health or dental plan originally chosen. A substantial change is determined by the hawk-i Board and means, but is not limited to, loss of a contracted hospital or provider group. When there is another participating health or dental plan available in the child’s county of residence, the child may disenroll from the current health or dental plan and enroll in the other health or dental plan for the remainder of the twelve-month period.

A child may disenroll from a health or dental plan at least every 12 months at the time of renewal. The Role of Federally Qualified Health Centers and Rural Health Centers Effective July 1, 2013, the hawk-i program, through the participating health plans, will reimburse Federally Qualified Health Centers (FHQC) and Rural Health Centers (RHC) as follows:

UnitedHealthcare UnitedHealthcare will contract with FQHCs and RHCs to reimburse FQHCs and RHCs at the most current Medicaid prospective payment system (PPS) to conform with the Benefits Improvements and Protections Act (BIPA) of 2000. There are no retroactive settlements required under the PPS.

Wellmark Health Plan of Iowa Wellmark Health Plan of Iowa (WHPI) will reimburse FQHCs and RHCs using an Alternative Payment Methodology (APM). WHPI will pay FQHCs and RHCs on a fee for service basis. WHPI will analyze the payments on a quarterly basis, comparing them to the BIPA rate. If the FQHC/RHC was paid more than the Medicaid BIPA rate, no additional payments are made. If the analysis shows that what the FQHC/RHC's have been paid from WHPI fee schedule was less than what they would have received with the Medicaid BIPA rate, a supplemental payment issued through the state, for the difference, is paid to the FQHC/RHC. All supplemental payments will be reviewed by the department.

The FQHCs and RHCs have agreed to each plan's payment methodology. See Attachment

19

Check here if the State child health program delivers services using a managed care delivery model. The State provides an assurance that its managed care contract(s) complies with the relevant provisions of section 1932 of the Act, including section 1932(a)(4), Process for Enrollment and Termination and Change of Enrollment; section 1932(a)(5), Provision of Information; section 1932(b), Beneficiary Protections; section 1932(c), Quality Assurance Standards; section 1932(d), Protections Against Fraud and Abuse; and section 1932(e), Sanctions for Noncompliance. The State also assures that it will submit the contract(s) to the CMS Regional Office for review and approval. (Section 2103(f)(3))

UnitedHealthcare and Wellmark Health Plan of Iowa are managed care plans. Each plan is required in their contract to comply with the relevant provisions of section 1932 of the Act.

Guidance: In Section 3.2., note that utilization control systems are those administrative mechanisms that are designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package.

Examples of utilization control systems include, but are not limited to: requirements for referrals to specialty care; requirements that clinicians use clinical practice guidelines; or demand management systems (e.g., use of an 800 number for after-hours and urgent care). In addition, the State should describe its plans for review, coordination, and implementation of utilization controls, addressing both procedures and State developed standards for review, in order to assure that necessary care is delivered in a cost-effective and efficient manner. (42CFR, 457.490(b))

3.2. Describe the utilization controls under the child health assistance provided under the plan for targeted low-income children. Describe the systems designed to ensure that enrollees receiving health care services under the State plan receive only appropriate and medically necessary health care consistent with the benefit package described in the approved State plan. (Section 2102)(a)(4) (42CFR 457.490(b))

Healthy And Well Kids in Iowa (hawk-i) Program Health and dental plans are allowed to establish limits for services and implement utilization management guidelines such as requiring prior authorization and using drug formularies as long as the plan provides the required services and meets benchmark equivalency. Plans may not deny coverage due to the existence of a pre-existing medical condition.

The State conducts periodic evaluations of each health plan for the purpose of reviewing the policies and procedures for utilization management, appeals and grievances, contract compliance, health education programs and materials, and the quality improvement program.

Children who are determined presumptively eligible for hawk-i, will receive the Title XIX benefit package until such time as eligibility is confirmed or denied. Title XIX offers services to persons eligible for Medicaid through a fee-for-service delivery system. Medically necessary services are

20 obtained by beneficiaries through contacted Medicaid providers. Children may obtain care from any contracted Medicaid provider of their choice.

When a formal eligibility determination of the presumptive eligibility application is complete, if eligible, the child will be enrolled for ongoing eligibility in the appropriate program, either Medicaid or hawk-i, based on established criteria.

Section 4. Eligibility Standards and Methodology

Guidance: States electing to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan or combination plan should check the appropriate box and provide the ages and income level for each eligibility group. If the State is electing to take up the option to expand Medicaid eligibility as allowed under section 214 of CHIPRA regarding lawfully residing, complete section 4.1-LR as well as update the budget to reflect the additional costs if the state will claim title XXI match for these children until and if the time comes that the children are eligible for Medicaid.

21 4.0. Medicaid Expansion

4.0.1. Ages of each eligibility group and the income standard for that group:

4.1.

Separate Program Check all standards that will apply to the State plan. (42CFR 457.305(a) and 457.320(a))

4.1.0 Describe how the State meets the citizenship verification requirements. Include whether or not State has opted to use SSA verification option.

The State has opted to use the SSA verification option.

4.1.1 Geographic area served by the Plan if less than Statewide:

4.1.2 Ages of each eligibility group, including unborn children and pregnant women (if applicable) and the income standard for that group:

Children up to age 19 are covered. Coverage ends effective the first day of the month following the month of the nineteenth birthday.

4.1.2.1-PC Age: through birth (SHO #02-004, issued November 12, 2002)

4.1.3 Income of each separate eligibility group (if applicable):

4.1.3.1-PC 0% of the FPL (and not eligible for Medicaid) through % of the FPL (SHO #02-004, issued November 12, 2002) 4.1.4 Resources of each separate eligibility group (including any standards relating to spend downs and disposition of resources):

4.1.5 Residency (so long as residency requirement is not based on length of time in state):

There is no minimum period of time in which the child must reside in the State to establish resdiency. A resident is one: a. Who is living in Iowa voluntarily with the intention of making that person's home in Iowa and not for a temporary purpose; or b. Who, at the time of application, is not receiving assistance from another state and entered Iowa with a job commitment or to seek employment or who is living with parents or guardians who entered Iowa with a job commitment or to seek employment.

4.1.6 Disability Status (so long as any standard relating to disability status does not restrict eligibility):

22 4.1.7 Access to or coverage under other health coverage:

A child who is covered under other health insurance is not eligible for coverage under hawk-i unless the coverage is a single service coverage such as a dental only or vision only policy. Access to coverage is not considered if the child is not actually covered.

4.1.8 Duration of eligibility, not to exceed 12 months:

The eligibility period is 12 months.

4.1.9 Other Standards- Identify and describe other standards for or affecting eligibility, including those standards in 457.310 and 457.320 that are not addressed above. For instance:

Inmates of nonmedical public institution. At the time of application or annual review of eligiblity, the child shall not be an inmate of a nonmedical public institution as define at 42 CFR Section 435.1009 as amended November 10,1994.

Inmates of institutions for mental disease. At the time of application or annual review of eligibility, the child shall not be an inmate of an institution for mental disease as defined at 42 CFR Section 435.1009 as amended November 10, 1994.

Guidance: States may only require the SSN of the child who is applying for coverage. If SSNs are required and the State covers unborn children, indicate that the unborn children are exempt from providing a SSN. Other standards include, but are not limited to presumptive eligibility and deemed newborns.

4.1.9.1

States should specify whether Social Security Numbers (SSN) are required.

Social Security Numbers are required only for children who are applying for the hawk-i program. Social Security Numbers are optional for those not applying to the program.

Guidance: States should describe their continuous eligibility process and populations that can be continuously eligible.

4.1.9.2 Continuous eligibility

4.1-PW

Pregnant Women Option (section 2112)- The State includes eligibility for one or more populations of targeted low-income pregnant women under the plan. Describe the population of pregnant women that the State proposes to cover in this section. Include all eligibility criteria, such as those described in the above categories (for instance, income and resources) that will be applied to this population. Use the same reference number

23 system for those criteria (for example, 4.1.1-P for a geographic restriction). Please remember to update sections 8.1.1-PW, 8.1.2-PW, and 9.10 when electing this option.

Guidance: States have the option to cover groups of “lawfully residing” children and/or pregnant women. States may elect to cover (1) “lawfully residing” children described at section 2107(e)(1)(J) of the Act; (2) “lawfully residing” pregnant women described at section 2107(e)(1)(J) of the Act; or (3) both. A state electing to cover children and/or pregnant women who are considered lawfully residing in the U.S. must offer coverage to all such individuals who meet the definition of lawfully residing, and may not cover a subgroup or only certain groups. In addition, states may not cover these new groups only in CHIP, but must also extend the coverage option to Medicaid. States will need to update their budget to reflect the additional costs for coverage of these children. If a State has been covering these children with State only funds, it is helpful to indicate that so CMS understands the basis for the enrollment estimates and the projected cost of providing coverage. Please remember to update section 9.10 when electing this option.

4.1- LR

Lawfully Residing Option (Sections 2107(e)(1)(J) and 1903(v)(4)(A); (CHIPRA # 17, SHO # 10-006 issued July 1, 2010) Check if the State is electing the option under section 214 of the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) regarding lawfully residing to provide coverage to the following otherwise eligible pregnant women and children as specified below who are lawfully residing in the United States including the following: A child or pregnant woman shall be considered lawfully present if he or she is: (1) A qualified alien as defined in section 431 of PRWORA (8 U.S.C. §1641); (2) An alien in nonimmigrant status who has not violated the terms of the status under which he or she was admitted or to which he or she has changed after admission; (3) An alien who has been paroled into the United States pursuant to section 212(d)(5) of the Immigration and Nationality Act (INA) (8 U.S.C. §1182(d)(5)) for less than 1 year, except for an alien paroled for prosecution, for deferred inspection or pending removal proceedings; (4) An alien who belongs to one of the following classes: (i) Aliens currently in temporary resident status pursuant to section 210 or 245A of the INA (8 U.S.C. §§1160 or 1255a, respectively); (ii) Aliens currently under Temporary Protected Status (TPS) pursuant to section 244 of the INA (8 U.S.C. §1254a), and pending applicants for TPS who have been granted employment authorization; (iii) Aliens who have been granted employment authorization under 8 CFR 274a.12(c)(9), (10), (16), (18), (20), (22), or (24); (iv) Family Unity beneficiaries pursuant to section 301 of Pub. L. 101- 649, as amended; (v) Aliens currently under Deferred Enforced Departure (DED) pursuant to a decision made by the President;

24 (vi) Aliens currently in deferred action status; or (vii) Aliens whose visa petition has been approved and who have a pending application for adjustment of status; (5) A pending applicant for asylum under section 208(a) of the INA (8 U.S.C. § 1158) or for withholding of removal under section 241(b)(3) of the INA (8 U.S.C. § 1231) or under the Convention Against Torture who has been granted employment authorization, and such an applicant under the age of 14 who has had an application pending for at least180 days; (6) An alien who has been granted withholding of removal under the Convention Against Torture; (7) A child who has a pending application for Special Immigrant Juvenile status as described in section 101(a)(27)(J) of the INA (8 U.S.C. §1101(a)(27)(J)); (8) An alien who is lawfully present in the Commonwealth of the Northern Mariana Islands under 48 U.S.C. § 1806(e); or (9) An alien who is lawfully present in American Samoa under the immigration laws of American Samoa.

Elected for pregnant women. Elected for children under age 19

4.1.1-LR The State provides assurance that for an individual whom it enrolls in Medicaid under the CHIPRA Lawfully Residing option, it has verified, at the time of the individual’s initial eligibility determination and at the time of the eligibility redetermination, that the individual continues to be lawfully residing in the United States. The State must first attempt to verify this status using information provided at the time of initial application. If the State cannot do so from the information readily available, it must require the individual to provide documentation or further evidence to verify satisfactory immigration status in the same manner as it would for anyone else claiming satisfactory immigration status under section 1137(d) of the Act.

4.1-DS

Supplemental Dental (Section 2103(c)(5) - A child who is eligible to enroll in dental- only supplemental coverage, effective January 1, 2009. Eligibility is limited to only targeted low-income children who are otherwise eligible for CHIP but for the fact that they are enrolled in a group health plan or health insurance offered through an employer. The State’s CHIP plan income eligibility level is at least the highest income eligibility standard under its approved State child health plan (or under a waiver) as of January 1, 2009. All who meet the eligibility standards and apply for dental-only supplemental coverage shall be provided benefits. States choosing this option must report these children separately in SEDS. Please update sections 1.1-DS, 4.2-DS, and 9.10 when electing this option.

25

4.2. Assurances The State assures by checking the box below that it has made the following findings with respect to the eligibility standards in its plan: (Section 2102(b)(1)(B) and 42 CFR 457.320(b))

4.2.1. These standards do not discriminate on the basis of diagnosis.

4.2.2. Within a defined group of covered targeted low-income children, these

standards do not cover children of higher income families without covering

children with a lower family income. This applies to pregnant women included

in the State plan as well as targeted low-income children.

4.2.3. These standards do not deny eligibility based on a child having a pre-existing

medical condition. This applies to pregnant women as well as targeted low-

income children.

4.2-DS Supplemental Dental - Please update sections 1.1-DS, 4.1-DS, and 9.10 when electing this option. For dental-only supplemental coverage, the State assures that it has made the following findings with standards in its plan: (Section 2102(b)(1)(B) and 42 CFR 457.320(b))

4.2.1-DS These standards do not discriminate on the basis of diagnosis.

4.2.2-DS Within a defined group of covered targeted low-income children, these

standards do not cover children of higher income families without covering

children with a lower family income.

4.2.3-DS These standards do not deny eligibility based on a child having a pre-

existing medical condition.

4.3. Methodology. Describe the methods of establishing and continuing eligibility and enrollment. The description should address the procedures for applying the eligibility standards, the organization and infrastructure responsible for making and reviewing eligibility determinations, and the process for enrollment of individuals receiving covered services, and whether the State uses the same application form for Medicaid and/or other public benefit programs. (Section 2102)(b)(2)) (42CFR, 457.350)

Initial Enrollment Applications for the hawk-i program are received via mail, fax, or on-line through the hawk-i web site by the third party administrator at a central location in Des Moines, Iowa. Applications are screened for completeness of information, the presence of other health insurance, verification of income, the presence of State of Iowa employment, and Medicaid eligibility. If it appears that a child is Medicaid eligible, the application is referred to a Medicaid eligibility worker co-located at the third party administrator's office for a Medicaid eligibility determination. Upon receipt of a completed application, the third party administrator must determine hawk-i eligibility within 10 working days. If it is determined the child is uninsured, that countable income does not exceed the hawk-i limit, and that the child otherwise qualifies, a notice of approval is sent to the family. Included with the approval notice is information about the health and dental plans available to the family and a Plan Selection form on which the family must make their selection. If countable income exceeds 150% of FPL but does not exceed 200 % of FPL, the family is also required to pay a premium of $10

26 per month per child, not to exceed $20 per month, regardless of family size. If countable income exceeds 200% of FPL but does not exceed 300% of FPL, the family is required to pay a premium of $20 per month per child, not to exceed $40 per month, regardless of family size. Cost sharing is not assessed to American Indian or Alaska Native children, regardless of income. Upon approval of an initial application, the first month for which a premium will be due is the third month following the month in which the approval letter was sent to the applicant. The first premium shall be due on the 10th calendar day of the second month following the month in which the approval letter was sent to the applicant. Note: An “initial application” is an application that is not an annual renewal. For the months of June 2008 and July 2008, the premiums for families with countable income that equals or exceeds 150% of FPL are waived. The basis for this waiver is good cause due to the financial hardship for those families with limited income in any of the Iowa counties that have been declared a disaster by the Governor of Iowa and/or Presidential Declaration of Disaster for Individual Assistance. Upon receipt of the Plan Selection form, the third party administrator notifies the health plan of the new enrollment. If the Plan Selection form is not returned by the due date, the third party administrator randomly assigns the family to a health plan. The family has thirty days to notify the third party administrator if they want to change the health plan. The health plan provides an identification card, an explanation of coverage, and a list of participating providers to the family.

Ongoing Eligibility During the 12-Month Enrollment Once eligibility is established, the child shall remain enrolled in the hawk-i program for a 12-month enrollment period unless one of the following occurs: a. The child moves to an area of the state not served by that plan. In which case, the child shall be enrolled in a participating plan in the new location. The enrollment period is the remaining months of the original 12-month enrollment. b. Age. The child shall be disenrolled from the hawk-i program as of the first day of the month following the month of the nineteenth birthday. c. Nonpayment of premiums. The child shall be disenrolled as of the first day of the month following the month in which premiums are not paid. If the family reports a decrease in income during the 12-month enrollment period, premium cost sharing is re-evaluated. If the family's income is reduced below 150 percent of FPL, the family will not have to pay a premium for the remaining months of the enrollment period. d. Iowa residence is abandoned. The child shall be disenrolled from the plan and canceled from the program as of the first day of the month following the month in which the child relocated to another state. e. Medicaid eligibility. The child shall be disenrolled from the plan and canceled from the program as of the first day of the month following the month in which Medicaid eligibility is attained. f. Enrolled in other health insurance. The child shall be disenrolled from the plan as of the first day of the month following the month in which the child attains other health insurance coverage. g. Admission to a nonmedical public institution. The child shall be disenrolled from the plan and canceled from the program as of the first day of the month in which the child enters a nonmedical public institution unless it can be established that the absence is temporary. h. Employment with the State of Iowa. The child shall be disenrolled from the plan and canceled from the hawk-i program as of the first day of the month in which the child's parent becomes eligible to

27 participate in a health plan available to State of Iowa employees.

Recertification All eligibility factors are reviewed annually as follows: a. Sixty (60) days prior to the end of the 12-month enrollment period, the third party administrator mail a hawk-i renewal application form to the family. The renewal application form is preprinted with the information known about the household. The family is asked to verify the correctness of the information and return the corrected form with current income verification. A postage-paid return envelope is provided. b. If the family fails to return the information or required income verification, the child shall not be recertified for the next 12-month enrollment period. c. Upon a determination that the child continues to meet all eligibility factors, the family shall be allowed to select another plan for the next 12-month enrollment period if another plan is available. If the family does not select another plan, the child shall be re-enrolled with the current plan for the next 12-month enrollment period.

Guidance: The box below should be checked as related to children and pregnant women. Please note: A State providing dental-only supplemental coverage may not have a waiting list or limit eligibility in any way.

4.3.1. Limitation on Enrollment Describe the processes, if any, that a State will use for instituting enrollment caps, establishing waiting lists, and deciding which children will be given priority for enrollment. If this section does not apply to your state, check the box below. (Section 2102(b)(2)) (42CFR, 457.305(b))

Check here if this section does not apply to your State.

Guidance: Note that for purposes of presumptive eligibility, States do not need to verify the

citizenship status of the child. States electing this option should indicate so in the

State plan. (42 CFR 457.355)

4.3.2. Check if the State elects to provide presumptive eligibility for children that meets the requirements of section 1920A of the Act. (Section 2107(e)(1)(L)); (42 CFR 457.355)

Presumptive Eligibility Staff of qualified entities selected and trained by the Medicaid state agency are authorized to determine presumptive eligibility. The eligibility income standard is income at or below 300% FPL. All presumptive eligibility applications are electronically referred to the Iowa Department of Human Services for an ongoing Medicaid or hawk-i eligibility determination. Medicaid eligibility is determined first. If the child is not eligible for Medicaid, the application is referred for a hawk-i eligibility determination.

Presumptive eligibility begins on the day the qualified entity determines that the child appears eligible and ends when one of the following occurs:

28 • the last day of the next calendar month after the month of application, OR • the day ongoing Medicaid is established, OR • the day the hawk-i eligibility decision is made, OR • the last day of next calendar month, after the month of application, if the Medicaid application is withdrawn.

Children who are determined presumptively eligible for hawk-i will receive the Title XIX benefit package until such time as eligibility is confirmed or denied. Title XIX offers services to persons eligible for Medicaid through a fee for service delivery system. Medically necessary services are obtained by beneficiaries through contracted Medicaid providers. Children may obtain care from any Contracted Medicaid provider of their choice.

Each child is eligible for only one period of presumptive eligibility within a twelve (12) month period. The 12-month period begins on the first day of presumptive eligibility determination.

When a formal eligibility determination of the presumptive eligibility application is complete, if eligible, the child will be enrolled for ongoing eligibility in the appropriate program, either Medicaid or hawk-i, based on established criteria.

Guidance: Describe how the State intends to implement the Express Lane option. Include information on the identified Express Lane agency or agencies, and whether the State will be using the Express Lane eligibility option for the initial eligibility determinations, redeterminations, or both.

4.3.3-EL Express Lane Eligibility Check here if the state elects the option to rely on a finding from an Express Lane agency when determining whether a child satisfies one or more components of CHIP eligibility. The state agrees to comply with the requirements of sections 2107(e)(1)(E) and 1902(e)(13) of the Act for this option. Please update sections 4.4-EL, 5.2-EL, 9.10, and 12.1 when electing this option. This authority may not apply to eligibility determinations made before February 4, 2009, or after September 30, 2013. (Section 2107(e)(1)(E))

4.3.3.1-EL Also indicate whether the Express Lane option is applied to (1) initial eligibility determination, (2) redetermination, or (3) both.

Express Lane option for hawk-i applies to initial and renewal eligiblity determinations.

4.3.3.2-EL List the public agencies approved by the State as Express Lane agencies.

For Medicaid. The express lane eligibility agency for Medicaid is Supplemental Nutrtion Assistance Program (SNAP). The child's household income as calculated by SNAP is used to determine eligibility for Medicaid. A Medicaid application is not required. The household must request medical assistance and return a signed form to the Medicaid office.

29 For hawk-i. The express lane eligiblity for the hawk-i program is Iowa Medicaid.

4.3.3.3-EL List the components/components of CHIP eligibility that are determined under the Express Lane. In this section, specify any differences in budget unit, deeming, income exclusions, income disregards, or other methodology between CHIP eligibility determinations for such children and the determination under the Express Lane option.

When a child is determined ineligible for Medicaid because they are over income at initial application, the Medicaid eligibility system automatically takes the eligibilty work to a screen on whlich to make an elctronic referral to the State's separate CHIP program. The notice of decision informing the family that the child is not eligible for Medicaid also informs the family that eligibility under the separate CHIP program is being examined.

Demographic data regrading the family and household income is electrnoically transferred to the Third Party Administrator's (TPA) proprietary systme for a determination of eligibility for the separate CHIP program. Demographic data includes whether citizenship and identity has been verified, the child's insured status, household composition, birthdates, social security numbers, etc. The income calculation used to determine Medicaid ineligiblilty is accepted by the TPA to etablish whether the child is under the income limits of the separate CHIP program. If the child is uninsured, citizenship and identity have been verified, and family income is under CHIP income limits, the child is enrolled in the program. If the child's citizenship and identity were not previously verified and a 90-day reasonable opportunity peirod has not been provided, the child is enrolled in the program and a 90-day period in which to verify stateus is provided.

If a child on Medicaid is found to be over income for Medicaid at the time of renewal, a referral to the separate CHIP program is made as described above.

If the Medicaid referral indicates the child is insured and/or that a reasonable opportunity period to verify citizenship and identity has been provided but verification has not been received, the application is denied.

4.3.3.3-EL List the component/components of CHIP eligibility that are determined under the Express Lane.

See above.

4.3.3.4-EL Describe the option used to satisfy the screen and enrollment requirements before a child may be enrolled under title XXI.

A Medicaid screen and enroll function is not performed by the TPA as part of the referral proces because the referral come from the Medicaid agency and ineligibility has already been established. The Medicaid screen and enroll process is completed when the family applies for the separate CHIP program first.

30 Guidance: States should describe the process they use to screen and enroll children required under section 2102(b)(3)(A) and (B) of the Social Security Act and 42 CFR 457.350(a) and 457.80(c). Describe the screening threshold set as a percentage of the Federal poverty level (FPL) that exceeds the highest Medicaid income threshold applicable to a child by a minimum of 30 percentage points. (NOTE: The State may set this threshold higher than 30 percentage points to account for any differences between the income calculation methodologies used by an Express Lane agency and those used by the State for its Medicaid program. The State may set one screening threshold for all children, based on the highest Medicaid income threshold, or it may set more than one screening threshold, based on its existing, age-related Medicaid eligibility thresholds.) Include the screening threshold(s) expressed as a percentage of the FPL, and provide an explanation of how this was calculated. Describe whether the State is temporarily enrolling children in CHIP, based on the income finding from an Express Lane agency, pending the completion of the screen and enroll process.

In this section, states should describe their eligibility screening process in a way that addresses the five assurances specified below. The State should consider including important definitions, the relationship with affected Federal, State and local agencies, and other applicable criteria that will describe the State’s ability to make assurances. (Sections 2102(b)(3)(A) and 2110(b)(2)(B)), (42 CFR 457.310(b)(2), 42CFR 457.350(a)(1) and 457.80(c)(3))

4.4. Eligibility screening and coordination with other health coverage programs States must describe how they will assure that:

4.4.1. only targeted low-income children who are ineligible for Medicaid or not covered under a group health plan or health insurance (including access to a State health benefits plan) are furnished child health assistance under the plan. (Sections 2102(b)(3)(A), 2110(b)(2)(B)) (42 CFR 457.310(b), 42 CFR 457.350(a)(1) and 42 CFR 457.80(c)(3)) Confirm that the State does not apply a waiting period for pregnant women.

Refer to response in 4.3 4.4.2. children found through the screening process to be potentially eligible for medical assistance under the State Medicaid plan are enrolled for assistance under such plan; (Section 2102(b)(3)(B)) (42CFR, 457.350(a)(2))

Refer to response in 4.3 4.4.3. children found through the screening process to be ineligible for Medicaid are enrolled in CHIP; (Sections 2102(a)(1) and (2) and 2102(c)(2)) (42CFR 431.636(b)(4))

Refer to response in 4.3 4.4.4. the insurance provided under the State child health plan does not substitute for coverage under group health plans. (Section 2102(b)(3)(C)) (42CFR, 457.805)

4.4.4.1. (formerly 4.4.4.4) If the State provides coverage under a premium

31 assistance program, describe: 1) the minimum period without coverage under a group health plan. This should include any allowable exceptions to the waiting period; 2) the expected minimum level of contribution employers will make; and 3) how cost-effectiveness is determined. (42CFR 457.810(a)-(c))

4.4.5. Child health assistance is provided to targeted low-income children in the State who are American Indian and Alaska Native. (Section 2102(b)(3)(D)) (42 CFR 457.125(a))

American Indian and Alaska Native Children are eligible for hawk-i program on the same basis as any other children in the State, regardless of whether or not they may be eligible for or served by Indian Health Services-funded care. No premiums or other cost sharing apply to American Indian or Alaska Native children.

Guidance: When the State is using an income finding from an Express Lane agency, the State must still comply with screen and enroll requirements before enrolling children in CHIP. The State may either continue its current screen and enroll process, or elect one of two new options to fulfill these requirements.

4.4-EL The State should designate the option it will be using to carry out screen and enroll

requirements:

The State will continue to use the screen and enroll procedures required under section 2102(b)(3)(A) and (B) of the Social Security Act and 42 CFR 457.350(a) and 42 CFR 457.80(c). Describe this process.

The State is establishing a screening threshold set as a percentage of the Federal poverty level (FPL) that exceeds the highest Medicaid income threshold applicable to a child by a minimum of 30 percentage points. (NOTE: The State may set this threshold higher than 30 percentage points to account for any differences between the income calculation methodologies used by the Express Lane agency and those used by the State for its Medicaid program. The State may set one screening threshold for all children, based on the highest Medicaid income threshold, or it may set more than one screening threshold, based on its existing, age-related Medicaid eligibility thresholds.) Include the screening threshold(s) expressed as a percentage of the FPL, and provide an explanation of how this was calculated.

The State is temporarily enrolling children in CHIP, based on the income finding from the Express Lane agency, pending the completion of the screen and enroll process.

Section 5. Outreach and Coordination

32 5.1. (formerly 2.2) Describe the current State efforts to provide or obtain creditable health coverage for uninsured children by addressing sections 5.1.1 and 5.1.2. (Section 2102)(a)(2) (42CFR 457.80(b))

Guidance: The information below may include whether the state elects express lane eligibility a description of the State’s outreach efforts through Medicaid and state- only programs.

5.1.1. (formerly 2.2.1.) The steps the State is currently taking to identify and enroll all uninsured children who are eligible to participate in public health insurance programs (i.e., Medicaid and state-only child health insurance):

Medicaid The Medicaid program is the only public health insurance program for children in Iowa. Medicaid is administered through the Department of Human Services (DHS) Central Office in Des Moines and through 104 DHS offices (including the Refugee Services Center) located in all 99 counties. Additionally, outstationed eligibility workers are currently located at Broadlawns Hospital in Des Moines. The University of Iowa in Iowa City has 6 intake positions.

There are five Federally Qualified Health Centers (FQHC) in Iowa. Currently there is one outstationed eligibility worker position at each of these sites.

Medicaid applications are readily available to anyone who requests one. Additionally, there is a toll-free number for anyone to call and ask questions about Medicaid eligibility and to find how to apply. The number is 1-800-869-6334.

In April 2000, Iowa had 129,192 children with health care coverage through the Medicaid program. Eligibility for Medicaid continues to remain available for the following federal categories of children. Those who qualify because they would have been eligible for cash assistance prior to July 16, 1996, and related categorical programs; those who are in foster care and subsidized adoption; those who qualify for the Mothers and Children program (SOBRA); those who meet disability criteria; those who are medically needy, and those who qualify under the following home and community based waivers:

Enrollment Cap Ill and Handicapped Waiver 1660 Mental Retardation Waiver 2348(for children) + 100 ICF/MR beds Brain Injury Waiver 372 AIDS Waiver 50 Physical Disability Waiver 144 Elderly Waiver Dependent on number of clients enrolled and amount of reimbursement for clients

Health Insurance Premium Payment Program (HIPP) Iowa was one of the first states to implement the provisions of section 1906 of the Social Security Act which mandated states to purchase employer-related health insurance coverage for Medicaid-eligible persons when it was determined cost-effective to do so. Iowa implemented the Health Insurance

33 Premium Payment (HIPP) program on July 1, 1991. Although section 1906 of the Social Security Act has now become optional, Iowa continues to maintain a strong HIPP program. Although this program is primarily designed to reduce Medicaid expenditures by providing a third party resource for Medicaid- eligible persons, oftentimes it is cost-effective to purchase family coverage which results in providing coverage for the non-Medicaid eligible household members as well. By initiating coverage while on Medicaid, families have coverage in place when they leave the Medicaid roles.

Direct Health Services (Title V, Title X, WIC, etc.) The Iowa Department of Public Health (IDPH) is the largest single provider of direct as well as support patient care for uninsured and Medicaid enrolled children and adolescents. Direct services for this population include: preventive child health services (EPSDT) and well-child check-ups, prenatal services, Women, Infants and Children Supplemental Nutrition (WIC) program services, preventive health education, immunizations, and family planning services. Support services include case coordination services, the provision of information and referral via toll-free telephone lines, and laboratory services. These services are funded through federal Title V Maternal and Child Health Block Grant funds, federal Title X Family programming funds, federal WIC Program funds, Medicaid program reimbursements, federal immunization funds, state legislative appropriations, some local government appropriations, and a small amount of patient fee revenue collected on a sliding fee scale by Title V agencies. A variety of the above direct and support services are provided within each of the 99 Iowa counties. Twenty-six Maternal Health Centers and twenty Child Health Centers provide statewide services. Adolescent services are provided in 25 locations in the state.

Additionally, there are approximately 486 full-time school health nurses working under the auspices of the Iowa Department of Education and local education agencies in the state who provide a variety of health screening services, care coordination and emergency services.

Income assessments are performed on patients enrolled in IDPH clinics. The income assessments are reviewed for possible Medicaid eligibility. New applications, as well as annual reviews of established patients, are assessed by IDPH intake staff and/or care coordinators for possible referral for medical assistance through Medicaid and/or SSI.

In order to provide additional outreach, The IDPH operates two toll-free telephone lines for use by the general public. The toll-free telephone lines are known as Healthy Families and Teen Line. These are information and referral services for health issues. The Healthy Families line addresses a wide variety of health issues with emphasis on prenatal care. The Teen Line also addresses a variety of issues specifically related to the health of teenagers. Topics covered include drugs, sexual relationships, eating disorders, relationships with parents, and violence. Two integral parts of the information provided to callers, via these telephone lines, are information on Medicaid eligibility and referrals to community based care coordinators who can assist clients with locating local health providers who accept Medicaid- eligible children and Medicaid-eligible pregnant women. The toll-free number for Health Families is 1- 800-369-2229. The Teen Line number is 1-800-443-8336. Both lines are operational 24 hours a day, seven (7) days a week.

Child Health Specialty Clinics

34 Each year, approximately 5,500 Iowa children receive services at the Child Health Specialty Clinics (CHSC). The Department of Human Services has an interagency cooperation agreement with the CHSC which serve as a link between major medical centers and the community by assisting families to obtain needed resources. The CHSC serves children from birth to 22 years with or at risk of a chronic health condition or disability, which includes psychosocial, physical, health-related educational and behavioral needs. The specific health concerns may be simple or complex, short-term or long-term.

Small Group Insurance Reform Iowa enacted small group reforms in 1992. These reforms provided more affordable coverage for the small group market, thus allowing employees and their dependents to obtain coverage at more affordable rates. The reforms included limitations on rate increases as well as limitations on pre-existing condition clauses.

In 1996, Iowa implemented individual market reforms which provide for portability for employees and their dependents form a group to the individual market, as well as rating restrictions on individual products.

State High Risk Insurance Pool Iowa law established a state administered high-risk health insurance program for those individuals and their dependents who cannot obtain coverage in the private market. This program is funded by a 2% tax on health insurance premiums. Persons who are eligible for Medicaid or COBRA continuation coverage are not eligible to participate in this program. Coverage in the high-risk program provides for individuals to the private market.

Express Lane Eligibility The State elects the Express Lane Eligibility option to rely on a finding of ineligibility from the Medicaid agency to determine eligibility for the separate CHIP program.

Guidance: The State may address the coordination between the public-private outreach and the public health programs that is occurring statewide. This section will provide a historic record of the steps the State is taking to identify and enroll all uninsured children from the time the State’s plan was initially approved. States do not have to rewrite his section but may instead update this section as appropriate.

5.1.2. (formerly 2.2.2.) The steps the State is currently taking to identify and enroll all uninsured children who are eligible to participate in health insurance programs that involve a public-private partnership:

Currently there are no health insurance programs that involve a public-private relationship. The Caring Program for Children There was one health insurance program in Iowa that resembled a public-private partnership. However, it was not administered by the State. This program was known as the Caring Program for Children and was administered by Wellmark (Blue Cross and Blue Shield of Iowa and South Dakota). The Iowa Caring Foundation provided ambulatory health

35 insurance to low income, non-Medicaid/uninsured children under the age of 19 years who remain full-time students through grade 12. During its 10 years of operation, the Caring Foundation was funded through a state appropriation and private donations, with matching funds from Wellmark. At its peak the Caring Program had an enrollment of over 3000 children. The Caring Program ceased operation on June 30, 1999.

Guidance: The State should describe below how it’s Title XXI program will closely coordinate the enrollment with Medicaid because under Title XXI, children identified as Medicaid- eligible are required to be enrolled in Medicaid. Specific information related to Medicaid screen and enroll procedures is requested in Section 4.4. (42CFR 457.80(c))

5.2. (formerly 2.3) Describe how CHIP coordinates with other public and private health insurance programs, other sources of health benefits coverage for children, other relevant child health programs, (such as title V), that provide health care services for low-income children to increase the number of children with creditable health coverage. (Section 2102(a)(3), 2102(b)(3)(E) and 2102(c)(2)) (42CFR 457.80(c)). This item requires a brief overview of how Title XXI efforts – particularly new enrollment outreach efforts – will be coordinated with and improve upon existing State efforts.

At the time a child is determined not to be eligible for hawk-i, the letter the applicant receives states: "Although you child does not qualify for hawk-i, health care services may be available through your local child health agency. For information about the child health center in your area, please call 1-800-369-2229 (Iowa Healthy Families Information and Referral Service)."

When it is determined that a child does not qualify or will no longer qualify for Medicaid due to excess income, a referral is made to hawk-i. The referral can be accomplished either electronically or using a paper form. In either format, the referral includes the name of the child (or children), the Medicaid application date (for children denied Medicaid) or the Medicaid end date (for children cancelled from Medicaid), and the reason for the referral. The electronic referral also includes the income amounts used to determine Medicaid ineligibility. A copy of the Medicaid notice of decision denying or cancelling Medicaid accompanies the paper referral. This notice contains a calculation showing how Medicaid ineligibility due to excess income was determined.

The third party administrator performs a comparison of hawk-i enrollees to Medicaid enrollees. A file containing the Medicaid enrollees is received and matched daily with the hawk-i enrollee file. If a match is found, the child is cancelled from hawk-i after being given notice of the cancellation.

If an individual applying for health services through a public health clinic also wishes to apply for Medicaid or hawk-i, the public health clinic will forward this information to hawk-i within two working days.

If an individual applying for WIC services also wishes to apply for Medicaid, the WIC agency will forward the information to Medicaid. If an individual applying for WIC appears to qualify for hawk-i, the individual is given a hawk-i enrollment form.

36 If a child applying for hawk-i is determined to be eligible for Medicaid, a referral for EPSDT is made. If a child or family asks about WIC, a WIC brochure along with the location of the nearest WIC is given to them.

In the action plans of the Title V agencies in Iowa, the Title V agencies have included outreach to hawk- i and Medicaid to children who may be eligible. The agencies will identify these children, notify the families of the program and advise them where and how to enroll and how to maintain the enrollment.

The Iowa Department of Human Services will be entering into a contract with the Iowa Department of Public Health to conduct grassroots outreach for the hawk-i and Medicaid programs. The Iowa Department of Public Health who oversees the Title V agencies, will ask the Title V agencies to either conduct the grassroots outreach activities or to subcontract with an agency or organization to do outreach. The Title V agencies will be responsible for doing a gap analysis to see what community agencies are currently doing for outreach as well as determine what is missing. The action plans must include the results of the gap analysis and what steps the agency will take to involve the community in conducting outreach.

5.2-EL The State should include a description of its election of the Express Lane eligibility option to provide a simplified eligibility determination process and expedited enrollment of eligible children into Medicaid or CHIP.

The State elects the Express Lane eligibility option to rely on a finding of ineligiblity from the Medicaid agency to determine eligibility for the separate CHIP program. The outreach coordinators in the local communities are taught that if a Medicaid application or renewal is over- income for Medicaid, an automated referral is made to hawk-i.

Guidance: Outreach strategies may include, but are not limited to, community outreach workers, outstationed eligibility workers, translation and transportation services, assistance with enrollment forms, case management and other targeting activities to inform families of low-income children of the availability of the health insurance program under the plan or other private or public health coverage.

The description should include information on how the State will inform the target of the availability of the programs, including American Indians and Alaska Natives, and assist them in enrolling in the appropriate program.

5.3. Strategies Describe the procedures used by the State to accomplish outreach to families of children likely to be eligible for child health assistance or other public or private health coverage to inform them of the availability of the programs, and to assist them in enrolling their children in such a program. (Section 2102(c)(1)) (42CFR 457.90)

Grassroots Outreach In July of 1999, the hawk-i Board directed the Iowa Department of Human Services to develop a grassroots outreach effort. The Department developed a plan by which communities would bring together those individuals and entities that touch the lives of families with children in order to develop a community outreach strategy. Once the plan was developed, it was submitted to the Department for

37 approval and funding was made available to assist in the implementation plan. Currently, the Department has 53 community outreach contracts that cover 89 counties.

Covering Kids Grant Project: Covering Kids is a 3-year grant that was awarded to the Iowa Department of Public Health in 1999 by the Robert Wood Johnson Foundation. The purpose of the grant is to increase access to health care coverage for all uninsured and underinsured children in Iowa. Administrators of the grant work collaboratively with the Iowa Department of Human Services, the Iowa Department of Education, advocates, medical providers, and others to address barriers to access for uninsured and underinsured children. This grant expires on June 30, 2002. As of July 1, 2002, the Iowa Department of Public Health will continue this work under a new 4-year Robert Wood Johnson Covering Kids and Families grant.

Mass Media Campaign During the spring of 2001, a short-term mass media campaign was used. Television commercials that had been produced for the national Insure Kids Now effort were used. Commercials were aired in both English and Spanish. Also a 60-second radio commercial in English and Spanish was produced. The commercials were aired for a seven-week period during March, April and May. There was an immediate response to the media campaign. During the six-month period prior to the campaign, the hawk-i customer service center received an average of 400 application requests per month. During the three months in which the commercials aired, application requests averaged 1,500 per month.

Other Media Ads have been placed in the Qwest Dex directory, in the yellow pages as well as the internet listing hawk-i 's toll free number. Ads have also occurred in various local and state newsletters, magazines, and other publications.

Partnering with Schools The Department of Human Services and the Department of Education collaborated to develop an interagency agreement that allowed schools and child care providers who participate in the Free and Reduced Meals Program to make referrals to the hawk-i Program for outreach purposes. Under this initiative, the names of applicants for the Free and Reduced Meals Program are referred to the hawk-i Program unless the family specifically asks not to be referred. Participating schools submitted a list of names to the hawk-i customer service center and then the customer service center mailed an application and information to the families. During the first year of this effort, applications were mailed to approximately 6,000 families. The Departments are working together to ensure this will be an ongoing effort.

Literacy Project Iowa was one of seven states selected to participate in a literacy project being conducted by the Centers for Medicare and Medicaid Services. The purpose of the project was to evaluate applications, brochures and other state-produced materials to assess how they could be modified to ensure comprehension by persons with very low literacy levels. Additionally, materials written in non-English languages were evaluated to see if they would meet the needs of the populations for which they were intended. These

38 findings are being utilized in the study to redesign the hawk-i application and brochure in order to remove as many barriers to enrollment as possible.

Multi-Language Poster The Department of Human Services introduced a new multi-language hawk-i poster in October 2001 in order to ensure that the needs of persons with limited English proficiency were being met. The poster provides information about the program in five languages: English, Spanish, Bosnian, Vietnamese, and Laotian. It also informs that translator services are available to assist them applications. The need for translation of information into these specific languages was identified through input of local outreach workers, the Bureau of Refugee Services, and use of AT&T translator lines by the hawk-i customer service center.

Corporate Involvement Nationally, there has been a growing interest by large corporations to assist states in promoting their SCHIP Program. Iowa actively takes advantage of these efforts to further promote the program. Some of these efforts in Iowa included:  Wal-Mart/Pampers  H&R Block  The Marmaxx In addition to the outreach activities aimed at enrolling eligible children, the state agencies' existing efforts to promote the use of health care services and continuity of care will also be expanded to include the new Title XXI enrollees. These activities include use of the media, case management, and patient follow-up systems, (especially within the Title V, Title X and Title XX Block Grant Programs, and related programs for children within the Iowa Department of Human Services).

Case management consists of a variety of activities designed to identify an individual patient's psychosocial needs and barriers to obtaining health services (such as enrolling in Medicaid), and assist the patient in meeting those needs and accessing services. Patient follow-up includes a variety of activities designed to ensure that patients comply with the recommendations of their health care provider(s) and continue in the health system.

One example of Iowa's continuing effort to improve the health status of school-aged children, the Project Success Program, coordinates social and health services with parental involvement in 13 designated school sites in the Des Moines school district. Project Success sites, which include seven elementary schools, two middle schools, two high schools, and two alternative high schools, refer potentially eligible Medicaid children for eligibility determination. Additionally, sixteen schools based/linked clinics provide services to school-aged children, their siblings and preschool aged children in the district. The clinics are required to assess income levels and refer those children who appear to be Medicaid eligible for eligibility determination while at the same time providing needed medical services. Outreach Activities from 2006 to present: Media Campaign: In September 2007, the DHS entered into a contract with ZLRIGNITION (ZLR), a media buyer, to develop a media campaign for the hawk-i and Medicaid program. ZLR conducted focus awareness groups of the hawk-i program. Based on the results of the focus groups, ZLR developed television, radio and print ads that focused on working families who do not have health insurance for

39 their children. See Attachment 15 for results.

Income Tax Match: In September 2008, DHS began working with the Iowa Department of Revenue to add a question to the Iowa 2008 tax forms for families about health care coverage for their children. Families who answered the question with no my children do not have health care coverage and who’s income was within the federal poverty were sent a hawk-i application by the Department of Revenue. This process will be further refined for the 2009 tax season. See Attachment 15 for results.

Outreach in local communities: In July 2006, DHS entered into contract with the Iowa Department of Public Health (IDPH) to conduct outreach in local communities. IDPH subcontracts with their Title V agencies for outreach activities. Such activities include, but are not limited to: health fair presentations, contacting local church and business and back to school registrations.

Free and Reduced Meals: In the 2007 Iowa legislative session, schools are mandated to provide names of children who participate in the free and reduced meal program as listed above in “Partnering with Schools”. Each year the process is further refined to make this process easier. DHS has also expanded this effort to include day care and preschools in addition to schools.

Section 6. Coverage Requirements for Children’s Health Insurance

Check here if the State elects to use funds provided under Title XXI only to provide expanded eligibility under the State’s Medicaid plan and proceed to Section 7 since children covered under a Medicaid expansion program will receive all Medicaid covered services including EPSDT.

6.1. The State elects to provide the following forms of coverage to children: (Check all that apply.) (Section 2103(c)); (42CFR 457.410(a))

Guidance: Benchmark coverage is substantially equal to the benefits coverage in a benchmark benefit package (FEHBP-equivalent coverage, State employee coverage, and/or the HMO coverage plan that has the largest insured commercial, non-Medicaid enrollment in the state). If box below is checked, either 6.1.1.1., 6.1.1.2., or 6.1.1.3. must also be checked. (Section 2103(a)(1))

6.1.1.

Benchmark coverage; (Section 2103(a)(1) and 42 CFR 457.420)

Guidance: Check box below if the benchmark benefit package to be offered by the State is the standard Blue Cross/Blue Shield preferred provider option service benefit plan, as described in and offered under Section 8903(1) of Title 5, United States Code. (Section 2103(b)(1) (42 CFR 457.420(b))

6.1.1.1.

FEHBP-equivalent coverage; (Section 2103(b)(1) (42 CFR 457.420(a)) (If checked, attach copy of the plan.)

Guidance: Check box below if the benchmark benefit package to be offered by the

40 State is State employee coverage, meaning a coverage plan that is offered and generally available to State employees in the state. (Section 2103(b)(2))

6.1.1.2.

State employee coverage; (Section 2103(b)(2)) (If checked, identify the plan and attach a copy of the benefits description.)

Guidance: Check box below if the benchmark benefit package to be offered by the State is offered by a health maintenance organization (as defined in Section 2791(b)(3) of the Public Health Services Act) and has the largest insured commercial, non-Medicaid enrollment of covered lives of such coverage plans offered by an HMO in the state. (Section 2103(b)(3) (42 CFR 457.420(c)))

6.1.1.3.

HMO with largest insured commercial enrollment (Section 2103(b)(3)) (If checked, identify the plan and attach a copy of the benefits description.)

Guidance: States choosing Benchmark-equivalent coverage must check the box below and ensure that the coverage meets the following requirements:  the coverage includes benefits for items and services within each of the categories of basic services described in 42 CFR 457.430: • dental services • inpatient and outpatient hospital services, • physicians’ services, • surgical and medical services, • laboratory and x-ray services, • well-baby and well-child care, including age-appropriate immunizations, and • emergency services;  the coverage has an aggregate actuarial value that is at least actuarially equivalent to one of the benchmark benefit packages (FEHBP-equivalent coverage, State employee coverage, or coverage offered through an HMO coverage plan that has the largest insured commercial enrollment in the state); and  the coverage has an actuarial value that is equal to at least 75 percent of the actuarial value of the additional categories in such package, if offered, as described in 42 CFR 457.430: • coverage of prescription drugs, • mental health services, • vision services and • hearing services.

If 6.1.2. is checked, a signed actuarial memorandum must be attached. The

41 actuary who prepares the opinion must select and specify the standardized set and population to be used under paragraphs (b)(3) and (b)(4) of 42 CFR 457.431. The State must provide sufficient detail to explain the basis of the methodologies used to estimate the actuarial value or, if requested by CMS, to replicate the State results.

The actuarial report must be prepared by an individual who is a member of the American Academy of Actuaries. This report must be prepared in accordance with the principles and standards of the American Academy of Actuaries. In preparing the report, the actuary must use generally accepted actuarial principles and methodologies, use a standardized set of utilization and price factors, use a standardized population that is representative of privately insured children of the age of children who are expected to be covered under the State child health plan, apply the same principles and factors in comparing the value of different coverage (or categories of services), without taking into account any differences in coverage based on the method of delivery or means of cost control or utilization used, and take into account the ability of a State to reduce benefits by taking into account the increase in actuarial value of benefits coverage offered under the State child health plan that results from the limitations on cost sharing under such coverage. (Section 2103(a)(2))

6.1.2.

Benchmark-equivalent coverage; (Section 2103(a)(2) and 42 CFR 457.430) Specify the coverage, including the amount, scope and duration of each service, as well as any exclusions or limitations. Attach a signed actuarial report that meets the requirements specified in 42 CFR 457.431.

See Attachment 3 for the benchmark plan.

Effective October 1, 2009, UnitedHealthcare Plan of the River Valley (See Attachment 4) and Wellmark Health Plan of Iowa (See Attachment 12) are the health plans participating in the hawk-i program. Delta Dental of Iowa is the dental plan (See Attachment 11).

Guidance: A State approved under the provision below, may modify its program from time to time so long as it continues to provide coverage at least equal to the lower of the actuarial value of the coverage under the program as of August 5, 1997, or one of the benchmark programs. If “existing comprehensive state-based coverage” is modified, an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of August 5, 1997, or one of the benchmark plans must be attached. Also, the fiscal year 1996 State expenditures for “existing comprehensive state-based coverage” must be described in the space provided for all states. (Section 2103(a)(3))

6.1.3.

Existing Comprehensive State-Based Coverage; (Section 2103(a)(3) and 42 CFR 457.440) This option is only applicable to New York, Florida, and Pennsylvania. Attach a description of the benefits package, administration, and date of

42 enactment. If existing comprehensive State-based coverage is modified, provide an actuarial opinion documenting that the actuarial value of the modification is greater than the value as of August 5, 1997 or one of the benchmark plans. Describe the fiscal year 1996 State expenditures for existing comprehensive state- based coverage.

Guidance: Secretary-approved coverage refers to any other health benefits coverage deemed appropriate and acceptable by the Secretary upon application by a state. (Section 2103(a)(4)) (42 CFR 457.250)

6.1.4.

Secretary-approved Coverage. (Section 2103(a)(4)) (42 CFR 457.450)

6.1.4.1.

Coverage the same as Medicaid State plan This coverage is only available to those found to be presumptively eligible for hawk-i. Services covered in Title XIX that are not covered in the separate CHIP program under XXI (hawk-i) are subject to the administrative expenditures under Title XXI.

6.1.4.2.

Comprehensive coverage for children under a Medicaid Section 1115 demonstration waiver

6.1.4.3.

Coverage that either includes the full EPSDT benefit or that the State has extended to the entire Medicaid population

Guidance: Check below if the coverage offered includes benchmark coverage, as specified in 457.420, plus additional coverage . Under this option, the State must clearly demonstrate that the coverage it provides includes the same coverage as the benchmark package, and also describes the services that are being added to the benchmark package.

6.1.4.4.

Coverage that includes benchmark coverage plus additional coverage

6.1.4.5.

Coverage that is the same as defined by existing comprehensive state- based coverage applicable only New York, Pennsylvania, or Florida (under 457.440)

Guidance: Check below if the State is purchasing coverage through a group health plan, and intends to demonstrate that the group health plan is substantially equivalent to or greater than to coverage under one of the benchmark plans specified in 457.420, through use of a benefit-by-benefit comparison of the coverage. Provide a sample of the comparison format that will be used. Under this option, if coverage for any benefit does not meet or exceed the coverage for that benefit under the benchmark, the State must provide an actuarial analysis as described in 457.431 to determine actuarial

43 equivalence.

6.1.4.6.

Coverage under a group health plan that is substantially equivalent to or greater than benchmark coverage through a benefit by benefit comparison (Provide a sample of how the comparison will be done)

Guidance: Check below if the State elects to provide a source of coverage that is not described above. Describe the coverage that will be offered, including any benefit limitations or exclusions.

6.1.4.7.