Section 441.86.1. Definitions.

“Applicant” shall mean anyone in the household, including all adults and children under the age of 19 who are counted in the HAWK-I 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 person or entity selected as the third-party administrator or the contract between the department and the participating health or dental plan for the provision of medical or dental services to HAWK-I 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 514I.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(514I).

“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 HAWK-I program as set forth in rule 441—86.2(514I).

“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.

“Family” shall mean anyone in the household, including all adults and children under the age of 19 who are counted in the HAWK-I family size according to the modified adjusted gross income methodology.

“Federal poverty 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 third-party administrator’s request for a reason not attributable to the enrollee. Lack of a forwarding address is attributable to the enrollee.

“HAWK-I board”  or “board”  shall mean the entity that adopts rules, establishes policy, and directs the department regarding the HAWK-I program.

“HAWK-I program”  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, as amended to October 1, 2008.

“Health Insurance Marketplace”  or “Exchange”  shall mean the entity authorized under 42 U.S.C. Section 18031(d)(4)(F) as amended to April 1, 2013, 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 435.1009 as amended November 10, l994.

“Modified adjusted gross income” shall mean the methodology prescribed in 42 U.S.C. Section 1396a(e)(14) and 42 CFR 435.603 as amended to April 1, 2013.

“Nonmedical 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 435.1009 as amended November 10, l994.

“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.

“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 HAWK-I program.

“Third-party administrator” shall mean the person or entity with which the department contracts to provide administrative services for the HAWK-I program.

[ARC 7770B, IAB 5/20/09, effective 7/1/09; ARC 8478B, IAB 1/13/10, effective 3/1/10; ARC 8580B, IAB 3/10/10, effective 3/1/10; ARC 0837C, IAB 7/24/13, effective 10/1/13]