Text: HF02367                           Text: HF02369
Text: HF02300 - HF02399                 Text: HF Index
Bills and Amendments: General Index     Bill History: General Index



House File 2368

Partial Bill History

Bill Text

PAG LIN
  1  1    Section 1.  NEW SECTION.  514I.1  DEFINITIONS.
  1  2    As used in this chapter, unless the context otherwise
  1  3 requires:
  1  4    1.  "Administrative contractor" means the person with whom
  1  5 the state enters a contract to administer the HAWK-I program
  1  6 under this chapter.
  1  7    2.  "Advisory board" or "board" means the entity which
  1  8 provides ongoing review and recommendations regarding the
  1  9 HAWK-I program.
  1 10    3.  "Cost sharing" means the payment of a premium or
  1 11 copayment as provided for by Title XXI of the federal Social
  1 12 Security Act and section 514I.8.
  1 13    4.  "Divisions" means the insurance division of the
  1 14 department of commerce and the division of medical services of
  1 15 the department of human services.
  1 16    5.  "Eligible child" means an individual who meets the
  1 17 criteria for participation in the program under section
  1 18 514I.6.
  1 19    6.  "HAWK-I program" or "program" means the healthy and
  1 20 well kids in Iowa program created in this chapter to provide
  1 21 health insurance coverage to eligible children.
  1 22    7.  "Health insurance coverage" means health insurance
  1 23 coverage as defined in 42 U.S.C. } 300gg(91).
  1 24    8.  "Participating insurer" means any entity licensed to
  1 25 provide health insurance in Iowa or an organized delivery
  1 26 system licensed by the director of public health that has
  1 27 contracted with the advisory board to offer health insurance
  1 28 coverage to eligible children under this chapter.
  1 29    9.  "Qualified child health plan" or "plan" means health
  1 30 insurance coverage provided by a participating insurer under
  1 31 this chapter.
  1 32    Sec. 2.  NEW SECTION.  514I.2  HAWK-I PROGRAM –
  1 33 ESTABLISHED – RULES.
  1 34    The division of insurance of the department of commerce and
  1 35 the division of medical services of the department of human
  2  1 services shall jointly establish a statewide program to
  2  2 provide health care coverage to eligible children on a
  2  3 regional basis which complies with Title XXI of the federal
  2  4 Social Security Act.  The program shall be administered by an
  2  5 administrative contractor under the direction of the advisory
  2  6 board.  Health insurance coverage under the program shall be
  2  7 provided by participating insurers.
  2  8    Sec. 3.  NEW SECTION.  514I.3  ADVISORY BOARD.
  2  9    1.  An advisory board for the HAWK-I program is established
  2 10 which shall consist of nine members, including, all of the
  2 11 following:
  2 12    a.  The commissioner of insurance, or the commissioner's
  2 13 designee.
  2 14    b.  The administrator of the division of medical services
  2 15 of the department of human services, or the administrator's
  2 16 designee.
  2 17    c.  A representative of physicians licensed pursuant to
  2 18 chapter 148, 150, or 150A, appointed by the governor.
  2 19    d.  A representative of hospitals licensed pursuant to
  2 20 chapter 135B, appointed by the governor.
  2 21    e.  A representative of health insurers, appointed by the
  2 22 governor.
  2 23    f.  A representative of health care consumers, appointed by
  2 24 the governor.
  2 25    g.  Three additional members, appointed by the governor.
  2 26    2.  Members appointed by the governor shall serve two-year
  2 27 terms.  Appointments shall comply with sections 69.16 and
  2 28 69.16A.  Vacancies shall be filled by the original appointing
  2 29 authority and in the manner of the original appointments.
  2 30    3.  The advisory board shall do all of the following:
  2 31    a.  Utilize a request for proposals process to select an
  2 32 administrative contractor for the program.
  2 33    b.  Define the regions of the state for which plans are
  2 34 offered.
  2 35    c.  Review the benefit package design on a periodic basis,
  3  1 and make necessary changes in the benefit design to reflect
  3  2 the results of the periodic reviews.
  3  3    d.  Develop an outreach plan for implementation by the
  3  4 administrative contractor.  The plan shall provide outreach to
  3  5 families of children likely to be eligible for assistance
  3  6 under the program or for other health insurance coverage, to
  3  7 inform them of the availability of and to assist the families
  3  8 in enrolling children in the program.  The outreach efforts
  3  9 shall include, but are not limited to, a comprehensive,
  3 10 statewide media campaign, solicitation of cooperation from
  3 11 programs, agencies, and other persons who are likely to have
  3 12 contact with eligible children, and the development of
  3 13 community plans for outreach and marketing.
  3 14    e.  Develop appropriate indicators to measure the health
  3 15 status of eligible children participating in the program.
  3 16    f.  Review and take necessary steps to improve interaction
  3 17 between the program and other public and private programs
  3 18 which provide services to the population of eligible children.
  3 19    g.  Develop a family satisfaction survey to be used by the
  3 20 administrative contractor in measuring consumer satisfaction
  3 21 with the program.
  3 22    h.  Make recommendations to the general assembly regarding
  3 23 legislation which would improve state law regarding the
  3 24 program and other related services to improve the health
  3 25 status of the population of eligible children.
  3 26    i.  Receive input from the public regarding the program and
  3 27 related issues and services.
  3 28    j.  Perform periodic random reviews of enrollee
  3 29 applications to assure compliance with program eligibility and
  3 30 enrollment policies.  Quality assurance reports shall be made
  3 31 based upon the data maintained by the administrative
  3 32 contractor.
  3 33    4.  The advisory board shall adopt rules which address all
  3 34 of the following:
  3 35    a.  Implementation and administration of the program.
  4  1    b.  The program application form.  The form shall include a
  4  2 request for information regarding other health insurance
  4  3 coverage for each child.
  4  4    c.  Criteria for the selection of an administrative
  4  5 contractor for the program.
  4  6    d.  Qualifying standards for selecting participating
  4  7 insurers for the program.
  4  8    e.  The benefits to be included in a qualified child health
  4  9 plan prior to June 30, 2000.
  4 10    f.  Standards for program eligibility.  The standards shall
  4 11 not discriminate on the basis of diagnosis.  Within a defined
  4 12 group of covered eligible children, the standards shall not
  4 13 cover children of higher income families without covering
  4 14 children of families with lower incomes.  The standards shall
  4 15 not deny eligibility based on a child having a preexisting
  4 16 medical condition.
  4 17    g.  Determination of program eligibility on a presumptive
  4 18 basis.  The rules shall provide that a participating insurer
  4 19 may determine a child to be presumptively eligible for a
  4 20 thirty-day period if it appears that the child will be
  4 21 eligible under the program, based upon review of a completed
  4 22 program application.  The rules shall also provide that the
  4 23 administrative contractor shall make the final determination
  4 24 of eligibility.  Following approval by the administrative
  4 25 contractor, a child shall be eligible for a twelve-month
  4 26 period, unless a change occurs in family income.  At the end
  4 27 of the twelve-month period, the child shall file a subsequent
  4 28 application for redetermination of eligibility.
  4 29    h.  The amount of any cost sharing under the program which
  4 30 shall be in an amount which complies with federal law but is a
  4 31 minimum of two percent of the gross annual income of the
  4 32 family of an eligible child.
  4 33    i.  The dates for periods of open enrollment and a
  4 34 requirement that an enrollee is locked into a qualified child
  4 35 health plan until the subsequent open enrollment period.
  5  1    j.  The reasons for disenrollment including, but not
  5  2 limited to, nonpayment of premiums, eligibility for medical
  5  3 assistance or other insurance coverage, admission to a public
  5  4 institution, relocation from the area, and change in income.
  5  5    Sec. 4.  NEW SECTION.  514I.4  PARTICIPATING INSURERS.
  5  6    Participating insurers shall meet the qualifying standards
  5  7 established by rule under this chapter and shall perform all
  5  8 of the following functions:
  5  9    1.  Receive completed program applications and
  5 10 verifications.
  5 11    2.  Within two days of receipt of a completed application,
  5 12 determine presumptive eligibility for the first month of
  5 13 coverage based on information presented.
  5 14    3.  Forward applications and eligibility verifications
  5 15 within two days to the administrative contractor for final
  5 16 eligibility determination.
  5 17    4.  Forward incomplete applications received to the
  5 18 administrative contractor for follow-up and completion.
  5 19    5.  Provide plan cards and membership booklets to
  5 20 qualifying families.
  5 21    6.  Provide program outreach to potential eligible children
  5 22 and market the features of the plan.
  5 23    7.  Provide or reimburse accessible, quality medical
  5 24 services.
  5 25    8.  Collect and retain monthly family premiums.
  5 26    9.  Track the monthly premiums to assure payments are up-
  5 27 to-date.
  5 28    10.  Verify that the payment of premiums is made for each
  5 29 month.
  5 30    11.  Inform the administrative contractor of information
  5 31 which might affect the eligibility of a child.
  5 32    12.  Create and maintain eligibility files that are
  5 33 compatible with the systems of the divisions.
  5 34    13.  Submit a marketing plan to the advisory board which is
  5 35 consistent with the advisory board's outreach plan, for
  6  1 approval by the board.
  6  2    14.  Provide the administrative contractor with all of the
  6  3 following information pertaining to the participating
  6  4 insurer's plan:
  6  5    a.  A list of providers of medical services under the plan.
  6  6    b.  Information regarding plan rules relating to referrals
  6  7 to specialists.
  6  8    c.  Information regarding the plan's complaint and
  6  9 grievance process.
  6 10    d.  Other information as directed by the advisory board.
  6 11    Sec. 5.  NEW SECTION.  514I.5  ADMINISTRATIVE CONTRACTOR.
  6 12    1.  An administrative contractor shall be selected by the
  6 13 advisory board through a request for proposals process.
  6 14    2.  The administrative contractor shall do all of the
  6 15 following:
  6 16    a.  Perform outreach activities, based upon the outreach
  6 17 plan developed by the advisory board, primarily through
  6 18 coordination with locally based outreach efforts.
  6 19    b.  Determine individual eligibility for program enrollment
  6 20 based upon review of completed applications and supporting
  6 21 documentation.  The administrative contractor shall not enroll
  6 22 a child whose family has employer-sponsored coverage available
  6 23 but whose family is not availing the family of that coverage,
  6 24 who has group health coverage or any child who has dropped
  6 25 coverage in the previous six months, unless the reason for
  6 26 dropping coverage is approved by the divisions.
  6 27    c.  Enroll qualifying children in the program with
  6 28 maintenance of a supporting eligibility file or data base.
  6 29    d.  Forward names of children who appear to be eligible for
  6 30 medical assistance or other public health insurance coverage
  6 31 to local department of human services offices or other
  6 32 appropriate person or agency for follow up and retain the
  6 33 identifying data on children who are referred.
  6 34    e.  Forward the names of children who appear to be eligible
  6 35 for participation in the program to all participating insurers
  7  1 for follow-up.
  7  2    f.  Monitor and assess the medical care provided through or
  7  3 by participating insurers as well as complaints and
  7  4 grievances.
  7  5    g.  Verify and forward to the divisions participating
  7  6 insurers' payment requests.
  7  7    h.  Develop a program application form, consistent with the
  7  8 rules of the advisory board, that is easy to understand,
  7  9 complete, and concise.
  7 10    i.  Develop and issue, upon notification from a
  7 11 participating insurer or upon the administrative contractor's
  7 12 own determination, denial letters for those children who are
  7 13 not or who are no longer eligible for participation in the
  7 14 program.
  7 15    j.  Create and maintain eligibility files that are
  7 16 compatible with the data systems of the divisions including,
  7 17 but not limited to, data regarding beneficiaries, enrollment
  7 18 dates, disenrollments, and annual financial redeterminations.
  7 19    k.  Provide participating insurers with the applications,
  7 20 processes, and procedures for determining presumptive
  7 21 eligibility, in accordance with rules.
  7 22    l.  Make program applications available through the mail
  7 23 and through local sites, as determined by the advisory board,
  7 24 including, but not limited to, schools, local health
  7 25 departments, local department of human services offices, and
  7 26 other locations.
  7 27    m.  Provide electronic access to the administrative
  7 28 contractor's database to the divisions.
  7 29    n.  Provide periodic reports to the advisory board for
  7 30 administrative oversight and monitoring of federal
  7 31 requirements.
  7 32    o.  Perform annual financial redeterminations of
  7 33 eligibility for each beneficiary.
  7 34    p.  Receive completed applications and verifications at a
  7 35 central location.
  8  1    q.  Verify documents and determine eligibility for the
  8  2 program.
  8  3    r.  Send notice to the family of each participating
  8  4 eligible child every six months as a reminder that the family
  8  5 must report substantial changes in the family's situation that
  8  6 may affect the child's eligibility for the program.
  8  7    s.  Process applications, including verifications and mail
  8  8 of approvals and disapprovals, within ten working days of
  8  9 receipt of the application.
  8 10    t.  Follow up on incomplete applications by telephone or
  8 11 mail.
  8 12    u.  For applications received from persons other than a
  8 13 participating insurer, provide the applicant with the
  8 14 applicant's choice of participating insurers in the
  8 15 applicant's area and enroll the eligible child with the
  8 16 participating insurer selected.
  8 17    v.  Notify each participating insurer of new program
  8 18 enrollees who are enrolled by the administrative contractor.
  8 19    w.  Verify the number of program enrollees with each
  8 20 participating insurer for determination of the amount of
  8 21 premiums to be paid to each participating insurer.
  8 22    x.  Maintain data for the purpose of quality assurance
  8 23 reports which includes, but is not limited to, all of the
  8 24 following:
  8 25    (1)  A list of enrollees by county for comparison with
  8 26 medical assistance recipients.
  8 27    (2)  The number of applications received.
  8 28    (3)  The number of denials of applications with the reasons
  8 29 for the denials.
  8 30    (4)  The number of children who were determined by the
  8 31 participating insurers to be program eligible, using
  8 32 presumptive eligibility, who were subsequently determined by
  8 33 the administrative contractor not to be program eligible.
  8 34    (5)  The number of children referred to the medical
  8 35 assistance program or other available coverage or services.
  9  1    (6)  The number of disenrollments with the reasons for
  9  2 disenrollments.
  9  3    (7)  The number of grievances or complaints received and
  9  4 their dispositions.
  9  5    (8)  The number of annual financial redeterminations.
  9  6    (9)  Enrollee survey results.
  9  7    (10)  Corrective actions with advisory board approval taken
  9  8 against each participating insurer regarding program
  9  9 compliance.
  9 10    (11)  The results of the measurement of indicators of the
  9 11 health status of eligible children participating in the
  9 12 program.
  9 13    y.  Conduct a consumer satisfaction survey, annually, using
  9 14 the survey developed by the advisory board.
  9 15    Sec. 6.  NEW SECTION.  514I.6  ELIGIBLE CHILD.
  9 16    A child may participate in the program if the child meets
  9 17 all of the following criteria:
  9 18    1.  Is less than nineteen years of age.
  9 19    2.  Is unmarried.
  9 20    3.  Is a resident of this state.
  9 21    4.  Is a member of a family whose adjusted gross income
  9 22 does not exceed one hundred eighty-five percent of the federal
  9 23 poverty level, as defined in 42 U.S.C. } 9902(2), including
  9 24 any revision required by such section.
  9 25    5.  Is not eligible for medical assistance as specified
  9 26 under the state plan in effect on June 1, 1997, under Title
  9 27 XIX of the federal Social Security Act.
  9 28    6.  Is not currently covered under or eligible for coverage
  9 29 under or was not covered or eligible for coverage within the
  9 30 prior six months under a group health plan as defined in 42
  9 31 U.S.C. } 300Ggg-91(a)(1) or other health benefit plan, unless
  9 32 the coverage was involuntarily lost.
  9 33    7.  Is not a member of a family that is eligible for health
  9 34 benefits coverage under a state health benefits plan on the
  9 35 basis of a family member's employment with a public agency in
 10  1 this state.
 10  2    8.  Is not an inmate of a public institution or a patient
 10  3 in an institution for mental diseases.
 10  4    Sec. 7.  NEW SECTION.  514I.7  PROGRAM BENEFITS.
 10  5    1.  Until June 30, 2000, the benefits provided under the
 10  6 program shall be those benefits provided under the Iowa
 10  7 healthy kids program pursuant to chapter 514H and in
 10  8 compliance with Title XXI of the federal Social Security Act.
 10  9    2.  On or before June 30, 1999, the advisory board shall
 10 10 adopt rules to amend the benefits package based upon review of
 10 11 the results of the initial benefits package used.  The
 10 12 benefits package shall only be changed if the advisory board
 10 13 determines that the new benefits package would be actuarially
 10 14 equivalent to the initial benefits package and in compliance
 10 15 with Title XXI of the federal Social Security Act.
 10 16    3.  Subsequent to June 30, 2000, the advisory board shall
 10 17 review the benefits package annually and shall determine
 10 18 additions to or deletions from the benefits package offered.
 10 19 The advisory board shall submit the recommendations to the
 10 20 general assembly for any amendment to the benefits package.
 10 21    4.  Benefits, in addition to those required by rule, may be
 10 22 provided to eligible children by a participating insurer if
 10 23 the benefits are provided at no additional cost to the state.
 10 24    Sec. 8.  NEW SECTION.  514I.8  COST SHARING AND PREMIUMS.
 10 25    1.  Cost sharing for eligible children whose family
 10 26 adjusted gross income is at or below one hundred fifty percent
 10 27 of the federal poverty level shall not exceed the standards
 10 28 permitted under 42 U.S.C. } 1396(o)(a)(3) or } 1396(o)(b)(1).
 10 29    2.  Cost sharing for eligible children whose family
 10 30 adjusted gross income is between one hundred fifty percent and
 10 31 one hundred eighty-five percent of the federal poverty level
 10 32 shall include a premium and coinsurance amount which is a
 10 33 minimum of two percent but which does not exceed five percent
 10 34 of the annual family adjusted gross income.  The amount of the
 10 35 premium and the coinsurance amount shall be based on a sliding
 11  1 fee scale established by rule which is based on family
 11  2 adjusted gross income and the size of the family.  
 11  3                           EXPLANATION
 11  4    This bill establishes the healthy and well kids in Iowa
 11  5 (HAWK-I) program to provide health care coverage for children
 11  6 who are eligible under Title XXI of the federal Social
 11  7 Security Act.  The bill provides that the division of
 11  8 insurance of the department of commerce and the division of
 11  9 medical services of the department of human services are to
 11 10 jointly establish the program and provides for the
 11 11 establishment of an advisory board for the program.  The
 11 12 program is to be administered by an administrative contractor
 11 13 who is selected by a request for proposals process.  The bill
 11 14 provides duties for the administrative contractor.  The bill
 11 15 also defines participating insurers and provides duties for
 11 16 participating insurers.  The bill also describes the benefit
 11 17 package to be provided under the program and provides for cost
 11 18 sharing by certain participants in the program.  
 11 19 LSB 3826YH 77
 11 20 pf/jw/5.2
     

Text: HF02367                           Text: HF02369
Text: HF02300 - HF02399                 Text: HF Index
Bills and Amendments: General Index     Bill History: General Index

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