Section 441.86.8. Premiums and copayments.

         86.8(1) Income considered. The income considered in determining the premium amount shall be the family’s countable income using the modified adjusted gross income methodology.

         86.8(2) Premium amount. Except as specified for supplemental dental-only coverage in subrule 86.20(3), premiums under the HAWK-I program shall be assessed as follows:

            a.               No premium is charged if:

             (1)             The eligible child is an American Indian or Alaskan Native; or

             (2)             The family’s countable income is less than 181 percent of the federal poverty level for a family of the same size.

            b.               If the family’s countable income is equal to or exceeds 181 percent of the federal poverty level for a family of the same size but does not exceed 242 percent of the federal poverty level for a family of that size, the premium is $10 per child per month with a $20 monthly maximum per family.

            c.               If the family’s countable income is equal to or exceeds 243 percent of the federal poverty level for a family of the same size, the premium is $20 per child per month with a $40 monthly maximum per family.

         86.8(3) Due date.

            a.                Payment upon initial application. “Initial application” means the first program application or a subsequent application that is not a renewal. Upon approval of an initial application, the first month for which a premium is due is the third month following the month of decision. The due date of the first premium shall be the fifth day of the second month following the month of decision.

            b.                Payment upon renewal. “Renewal” means any application used to establish ongoing eligibility, without a break in coverage, for any enrollment period subsequent to an enrollment period established by an initial application.

             (1)             Upon approval of a renewal, the first month for which a premium is due is the first month of the enrollment period. The premium for the first month of the enrollment period shall be due by the fifth day of the month before the month of coverage or the tenth business day following the date of decision, whichever is later.

             (2)             All premiums due must be paid before the child will be enrolled for coverage. When the premium is received, the third-party administrator shall notify the health and dental plans of the enrollment.

            c.                Subsequent payments. All subsequent premiums are due by the fifth day of each month for the next month’s coverage and must be postmarked no later than the last day of the month before the month of coverage. Premiums may be paid in advance (e.g., on a quarterly or semiannual basis) rather than a monthly basis.

            d.                Holiday or weekend. When the premium due date falls on a holiday or weekend, the premium shall be due on the first business day following the due date.

         86.8(4) Grace period. A grace period shall be allowed on any monthly premium not received as prescribed in paragraph 86.8(3)“c.” The grace period shall be the coverage month for which the premium is due.

            a.              Failure to submit a premium by the last calendar day of the grace period shall result in disenrollment.

            b.               If the premium is subsequently received, coverage will be reinstated if the premium was postmarked or otherwise paid:

             (1)             In the grace period, or

             (2)             In the 14 calendar days following the grace period.

         86.8(5) Method of premium payment. Premiums may be submitted in the form of cash, personal checks, electronic funds transfers (EFT), or other methods established by the third-party administrator.

         86.8(6) Failure to pay premium. Failure to pay the premium in accordance with subrules 86.8(3) and 86.8(5) shall result in cancellation from the program unless the grace period provisions of subrule 86.8(4) apply. Once a child is canceled from the program due to nonpayment of premiums, the family must reapply for coverage.

         86.8(7) Copayment. There shall be a $25 copayment for each emergency room visit if the child’s medical condition does not meet the definition of emergency medical condition.

Exception: A copayment shall not be imposed when family income is less than 150 percent of the federal poverty level for a family of the same size or when the child is an eligible American Indian or Alaskan Native.

         86.8(8) Program lock-out. A child who has been disenrolled from the program due to nonpayment of premiums shall be locked out of the program until the arrearage is paid in full or for a period not to exceed 90 days, whichever occurs first.

            a.               Failure to pay the unpaid premiums shall result in denial of the application if less than 90 days has elapsed since the effective date of disenrollment. Exception: The unpaid premium obligation shall be reduced to zero if upon reapplication a premium would not be assessed because the household’s income is less than 150 percent of the federal poverty level.

            b.               If the arrearage is not paid within 24 months of failing to pay a premium, the debt shall be expunged and shall no longer be owed.

[ARC 7770B, IAB 5/20/09, effective 7/1/09; ARC 8478B, IAB 1/13/10, effective 3/1/10; ARC 9083B, IAB 9/22/10, effective 9/1/10; ARC 0837C, IAB 7/24/13, effective 10/1/13; ARC 1287C, IAB 1/8/14, effective 1/1/14]