Iowa Admin. Code r. 441-86.8 - Premiums and copayments
(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.
(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 .
(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
department 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. 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.
(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 month immediately following the last month for which the
premium has been paid.
a. Failure to submit a
premium by the last calendar day of the grace period shall result in
disenrollment.
b. If the premium
for the grace period and the premium for the following month's coverage is
subsequently received within 45 calendar days following the last calendar day
of the grace period, coverage will be reinstated, effective the first day of
the calendar month following the grace period, without the need to reapply for
coverage.
(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 department .
(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.
(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
Notes
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