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

Effective Date:

Approval Date: 49

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.