Page 25

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

Effective Date:

Approval Date: 25

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