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

Effective Date:

Approval Date: 9 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 or exceeds 150% who reside 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

1.4-DS For dental-only supplemental coverage, please provide the effective (date costs begin to be incurred) and implementation (date services begin to be provided) dates for this plan or plan amendment (42 CFR 457.65):

Effective date: 3-1-10 Implementation date: 3-1-10