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

Effective Date:

Approval Date: 21

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