Section 441.86.13. Third-party administrator.

The third-party administrator shall have the following responsibilities:

       86.13(1) Determination of eligibility. Eligibility for the HAWK-I program shall be determined utilizing the department’s eligibility system and in accordance with the provisions of rule 441—86.2(514I).

       86.13(2) Dissemination of application forms and information. The third-party administrator shall disseminate the following:

        a.           Rescinded IAB 10/17/01, effective 12/1/01.

        b.           Outreach materials, application forms, or other materials developed and produced by the department to any organization or individual making a request for the materials. If the request is for quantities exceeding ten, the third-party administrator shall forward the request to Iowa prison industries for dissemination.

        c.           Participating health and dental plan information.

        d.           Other materials as specified by the department.

       86.13(3) Toll-free dedicated customer services line. The third-party administrator shall maintain a toll-free multilingual dedicated customer service line in accordance with the requirements of the department.

       86.13(4) HAWK-I program web site. The third-party administrator shall work in cooperation with the department to maintain a web site providing information about the HAWK-I program.

       86.13(5) Application process. Applications shall be processed in accordance with the provisions of rule 441—86.3(514I).

        a.           Processing applications and mailing of approvals and denials shall be completed within ten working days of receipt of the application and all necessary information and verification unless the application cannot be processed within this period for a reason beyond the control of the third-party administrator.

        b.           Original verification information shall be returned to the applicant or enrollee upon completion of review.

        c.           Applications shall be screened for completeness. Additional information or verification necessary to establish eligibility may be requested in writing. All information or verification of information attained shall be logged.

        d.           Health and dental plans shall be notified when the number of enrollees who speak the same non-English language equals or exceeds 10 percent of the number of enrollees in the health or dental plan.

       86.13(6) Effective date of coverage. The effective date of coverage shall be established in accordance with the provisions of rule 441—86.5(514I).

       86.13(7) Selection of health or dental plan. The third-party administrator shall provide participating health and dental plan information to families of eligible children by telephone or mail and, if necessary, offer unbiased assistance in the selection of a health or dental plan in accordance with the provisions of rule 441—86.6(514I).

       86.13(8) Enrollment. The third-party administrator shall notify participating health and dental plans of enrollments.

       86.13(9) Disenrollments. The third-party administrator shall disenroll an enrollee when the enrollee’s eligibility for the HAWK-I program is canceled in accordance with the provisions of rule 441—86.7(514I). The third-party administrator shall notify the participating health and dental plans when an enrollee is disenrolled.

       86.13(10) Annual reviews of eligibility. Eligibility shall be reviewed annually in accordance with the provisions of rules 441—86.2(514I) and 441—86.9(514I).

       86.13(11) Acting on reported changes. The third-party administrator shall ensure that all changes reported by the HAWK-I enrollee in accordance with rule 441—86.10(514I) are acted upon no later than ten working days from the date the change is reported.

       86.13(12) Premiums. The third-party administrator shall:

        a.           Calculate premiums in accordance with the provisions of rule 441—86.8(514I).

        b.           Collect HAWK-I premium payments. The funds shall be deposited into an interest-bearing account maintained by the department for periodic transmission of the funds and any accrued interest to the HAWK-I trust fund in accordance with state accounting procedures.

        c.           Track the status of the enrollee premium payments and provide the data to the department.

        d.           Mail a reminder notice to the family if the premium is not received by the due date.

       86.13(13) Notices to families. Timely and adequate approval, denial, and cancellation notices that clearly explain the action being taken in regard to an application or an existing enrollment shall be issued to the family. Denial and cancellation notices shall clearly explain the appeal rights of the applicant or enrollee. All notices shall be available in English and Spanish.

       86.13(14) Records. The third-party administrator shall at a minimum maintain the following records:

        a.           All records required by the department and the department of inspections and appeals.

        b.           Records which identify transactions with or on behalf of each enrollee by social security number or other unique identifier.

        c.           Application, case and financial records.

        d.           All other records as required by the department in determining compliance with any federal or state law or rule or regulation promulgated by the United States Department of Health and Human Services or by the department.

       86.13(15) Confidentiality. The third-party administrator shall protect and maintain the confidentiality of HAWK-I applicants and enrollees in accordance with 441—Chapter 9.

       86.13(16) Reports to the department. The third-party administrator shall submit reports as required by the department.

       86.13(17) Systems. The third-party administrator shall maintain data files that are compatible with the department’s and the health plans’ data files and shall make the system accessible to department staff.

[ARC 8478B, IAB 1/13/10, effective 3/1/10; ARC 0837C, IAB 7/24/13, effective 10/1/13]