"Applicant" shall mean anyone in the
household, including all adults and children under the age of 19 who are
counted in the hawki family size according to the modified adjusted gross
income methodology and who are listed on the application or renewal
form.
"Benchmark benefit package for health care
coverage" shall mean any of the following:
1. The standard Blue Cross Blue Shield preferred provider
option service benefit plan, described in and offered under
5 U.S.C. Section
8903(1).
2. A health benefits coverage plan that is offered and
generally available to state employees in this state.
3. The plan of a health maintenance organization, as defined
in
42 U.S.C. Section
300e, with the largest insured commercial,
nonmedical assistance enrollment of covered lives in the state.
"Capitation rate" shall mean the fee the
department pays monthly to a participating health or dental plan for each
enrollee for the provision of covered medical or dental services whether or not
the enrollee received services during the month for which the fee is
intended.
"Contract" shall mean the contract between
the department and the participating health or dental plan for the provision of
medical or dental services to hawki enrollees for whom the participating health
or dental plans assume risk.
"Cost sharing" shall mean the payment of a
premium or copayment as provided for by Title XXI of the federal Social
Security Act and Iowa Code section 5141.10.
"Countable income" shall mean earned and
unearned income of the family according to the modified adjusted gross income
methodology.
"Covered services" shall mean all or a part
of those medical and dental services set forth in rule
441-86.14 (5141).
"Dentist" shall mean a person who is
licensed to practice dentistry.
"Department" shall mean the Iowa department
of human services.
"Director" shall mean the director of the
Iowa department of human services.
"Eligible child" shall mean an individual
who meets the criteria for participation in the hawki program as set forth in
rule 441-86.2 (5141).
"Emergency dental condition" shall mean an
oral condition that occurs suddenly and creates an urgent need for professional
consultation or treatment. Emergency conditions may include hemorrhage,
infection, pain, broken teeth, knocked-out teeth, or other trauma.
"Emergency medical condition" shall mean a
medical condition manifesting itself by acute symptoms of sufficient severity,
including severe pain, such that a prudent layperson, who possesses an average
knowledge of health and medicine, could reasonably expect the absence of
immediate medical attention to result in one of the following:
1. Placing the health of the person or, with respect to a
pregnant woman, the health of the woman and her unborn child, in serious
jeopardy,
2. Serious impairment to bodily functions, or
3. Serious dysfunction of any bodily organ or part.
"Emergency services" shall mean, with
respect to an individual enrolled with a plan, covered inpatient and outpatient
services which are furnished by a provider qualified to furnish these services
and which are needed to evaluate and stabilize an emergency medical or dental
condition.
"Enrollee" shall mean a child who has been
determined eligible for the program and who has been enrolled with a
participating health plan.
"Enrollment broker" shall mean the entity
the department uses to enroll eligible children with a managed care
organization. The enrollment broker must be conflict-free and meet all
applicable requirements of state and federal law.
"Family" shall mean anyone in the household,
including all adults and children under the age of 19 who are counted in the
hawki family size according to the modified adjusted gross income
methodology.
"Federalpoverty level" shall mean the
poverty income guidelines revised annually and published in the Federal
Register by the United States Department of Health and Human Services.
"Good cause" shall mean the family has
demonstrated that one or more of the following conditions exist:
1. There was a serious illness or death of the enrollee or a
member of the enrollee's family.
2. There was a family emergency or household disaster, such
as a fire, flood, or tornado.
3. There was a reason beyond the enrollee's control.
4. There was a failure to receive the department's request
for a reason not attributable to the enrollee. Lack of a forwarding address is
attributable to the enrollee.
"Hawki board" or "board"
shall mean the entity that adopts rules, establishes policy, and directs the
department regarding the hawki program.
"Hawkiprogram" or "program"
shall mean the healthy and well kids in Iowa program implemented in this
chapter to provide health and dental care coverage to eligible children.
"Health insurance coverage" shall mean
health insurance coverage as defined in
45
CFR Section 144.103.
"Health Insurance Marketplace" or
"Exchange" shall mean the entity authorized under
42 U.S.C. Section
18031(d)(4)(F) to evaluate
and determine eligibility of applicants for Medicaid, the Children's Health
Insurance Program (CHIP), and other health programs.
"Institution for mental diseases" shall mean
a hospital, nursing facility, or other institution of more than 16 beds that is
primarily engaged in providing diagnosis, treatment, or care of persons with
mental diseases, including medical attention, nursing care and related services
as defined at
42 CFR Section
435.1010.
"Modified adjusted gross income" shall mean
the methodology prescribed in
42 U.S.C. Section
1396a(e)(14) and 42 CFR
435.603.
"
Public institution" shall mean an
institution that is the responsibility of a governmental unit or over which a
governmental unit exercises administrative control as defined in
42 CFR Section
435.1010.
"Participating dental plan" shall mean any
entity licensed by the division of insurance of the department of commerce to
provide dental insurance in Iowa that has contracted with the department to
provide dental insurance coverage to eligible children under this
chapter.
"Participating health plan" shall mean any
entity licensed by the division of insurance of the department of commerce to
provide health insurance in Iowa or an organized delivery system licensed by
the director of public health that has contracted with the department to
provide health insurance coverage to eligible children under this
chapter.
"Passive enrollment process" shall mean the
process by which the department assigns a child to a participating health or
dental plan and which seeks to preserve existing provider-enrollee
relationships, if possible. In the absence of existing relationships, the
process ensures that members are equally distributed among all available health
or dental plans.
"Physician" shall be defined as provided in
Iowa Code subsection
135.1(4).
"Provider" shall mean an individual, firm,
corporation, association, or institution that is providing or has been approved
to provide medical or dental care or services to an enrollee pursuant to the
hawki program.
