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

Effective Date:

Approval Date: 19

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