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

Effective Date:

Approval Date: 8 Amendment 7 Expansion of counties for Iowa Health Solutions 6-1-2003 and elimination of 6-month waiting period 7-1-2003. Amendment 8 Electronic Medicaid referral process 7-1-04, adding dental only plans 01-01-05, and withdrawal of Iowa Health Solutions 2-1-05 Amendment 9 Expansion of counties for John Deere and Delta Dental 3-1- 06 Amendment 10 Name change for John Deere Health Plan. New name is AmeriChoice from UnitedHealthcare of the River Valley (AmeriChoice) 7-1-06; Addition of Wellmark Health Plan of Iowa (WHPI) health plan 7-24-06; Expansion of WHPI counties 9-1-06; Expansion of counties for AmeriChoice and Delta Dental Plan of Iowa counties 9-15-06. Amendment 11 Expansion of counties for Wellmark Health Plan of Iowa 7-1-07 Amendment 12 Waiver of cost sharing premiums for families with countable income that equals exceeds 150% who are eligible for Iowa‟s disaster assistance for June and July 2008 - 6-1-08 Amendment 13 Increasing hawk-i income limits to 300% of the FPL. 7-1-09 Amendment 14 Coverage of Lawfully Residing Aliens 7-1-09 Withdrawal of Wellmark Blue Cross Blue Shield of Iowa (Classic Blue) 10-1-09; Name change for AmeriChoice from UnitedHealthcare of the River Valley to UnitedHealthcare of the River Valley (UHC) 11-1-09; Expansion of UHC, 3-1-10; Changes to dental benefits, 3-1-10

Implementation date: Amendment 7 Expansion of counties for Iowa Health Solutions 6-1-2003 and elimination of 6-month waiting period 7-1-2003 Amendment 8 Electronic Medicaid referral process 7-1-04, adding dental only plans 01-01-05, and withdrawal of Iowa Health Solutions 2-1-05 Amendment 9 Expansion of counties for John Deere and Delta Dental, 3-1-06 Amendment 10 Name change for John Deere Health Plan. New name is AmeriChoice from UnitedHealthcare of the River Valley (AmeriChoice) 7-1-06; Addition of Wellmark Health Plan of