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

Effective Date:

Approval Date: 20

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