Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 86 - Healthy and Well Kids in Iowa (HAWK-I) Program › Rule 441-86.1 - Definitions

Current through Register Vol. 47, No. 3, July 24, 2024
"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.