1. A HAWK-I board for the HAWK-I program is established. The board shall meet not less than ten times annually, for the purposes of establishing policy for, directing the department on, and adopting rules for the program. The board shall consist of seven members, including all of the following:
a. The commissioner of insurance, or the commissioner's designee.
b. The director of the department of education, or the director's designee.
c. The director of public health, or the director's designee.
d. Four public members appointed by the governor and subject to confirmation by the senate. The public members shall be members of the general public who have experience, knowledge, or expertise in the subject matter embraced within this chapter.
e. Two members of the senate and two members of the house of representatives, serving as ex officio members. The legislative members of the board shall be appointed by the majority leader of the senate, after consultation with the president of the senate, and by the minority leader of the senate, and by the speaker of the house, after consultation with the majority leader, and by the minority leader of the house of representatives. Legislative members shall receive compensation pursuant to section 2.12.
2. A public member shall not have a conflict of interest with the administrative contractor.
3. Members appointed by the governor and legislative members of the board shall serve two-year terms. The filling of positions reserved for the public representatives, vacancies, membership terms, payment of compensation and expenses, and removal of the members are governed by chapter 69. Members of the board are entitled to receive reimbursement of actual expenses incurred in the discharge of their duties. Public members of the board are also eligible to receive compensation as provided in section 7E.6. The members shall select a chairperson on an annual basis from among the membership of the board.
4. The board shall approve any contract entered into pursuant to this chapter. All contracts entered into pursuant to this chapter shall be made available to the public.
5. The department of human services shall act as support staff to the board.
6. The board may receive and accept grants, loans, or advances of funds from any person and may receive and accept from any source contributions of money, property, labor, or any other thing of value, to be held, used, and applied for the purposes of the program.
7. The HAWK-I board shall do all of the following:
a. Develop the criteria to be included in a request for proposals for the selection of any administrative contractor for the program.
b. Define, in consultation with the department, the regions of the state for which plans are offered in a manner as to ensure access to services for all children participating in the program.
c. Approve the benefit package design, review the benefit package design on a periodic basis, and make necessary changes in the benefit design to reflect the results of the periodic reviews.
d. Develop, with the assistance of the department, an outreach plan for implementation by the administrative contractor, and provide for periodic assessment of the effectiveness of the outreach plan. The plan shall provide outreach to families of children likely to be eligible for assistance under the program or for other health insurance coverage or care programs, to inform them of the availability of and to assist the families in enrolling children in the program. The outreach efforts shall include, but are not limited to, a comprehensive statewide media campaign, solicitation of cooperation from programs, agencies, and other persons who are likely to have contact with eligible children, including but not limited to those associated with the educational system, and the development of community plans for outreach and marketing.
e. In consultation with the clinical advisory committee, select a single, nationally recognized functional health assessment form for an initial assessment of all eligible children participating in the program, establish a baseline for comparison purposes, and develop appropriate indicators to measure the health status of eligible children participating in the program.
f. Review, in consultation with the department, and take necessary steps to improve interaction between the program and other public and private programs which provide services to the population of eligible children. The board, in consultation with the department, shall also develop and implement a plan to improve the medical assistance program in coordination with the HAWK-I program, including but not limited to a provision to coordinate eligibility between the medical assistance program and the HAWK-I program, and to provide for common processes and procedures under both programs to reduce duplication and bureaucracy.
g. By January 1, annually, prepare, with the assistance of the department, and submit a report to the governor, the general assembly, and the council on human services, concerning the board's activities, findings, and recommendations.
h. Solicit input from the public regarding the program and related issues and services.
i. Perform periodic random reviews of enrollee applications to assure compliance with program eligibility and enrollment policies. Quality assurance reports shall be made based upon the data maintained by the administrative contractor.
j. Establish and consult with a clinical advisory committee to make recommendations to the board regarding the clinical aspects of the HAWK-I program.
k. Prescribe the elements to be included in a health improvement program plan required to be developed by a participating insurer. The elements shall include but are not limited to health maintenance and prevention and health risk assessment.
l. Establish an advisory committee to make recommendations to the board and to the general assembly on or before January 1, 1999, concerning the provision of health insurance coverage to children with special health care needs under the program. The committee shall include individuals with experience in, knowledge of, or expertise in this area. The recommendations shall address, but are not limited to, all of the following:
(1) The definition of the target population of children with special health care needs for the purposes of determining eligibility under the program.
(2) Eligibility options for and assessment of children with special health care needs for eligibility.
(3) Benefit options for children with special health care needs.
(4) Options for enrollment of children with special health care needs in and disenrollment of children with special health care needs from qualified child health plans utilizing a capitated fee form of payment.
(5) The appropriateness and quality of care for children with special health care needs.
(6) The coordination of health services provided for children with special health care needs under the program with services provided by other publicly funded programs.
8. The HAWK-I board, in consultation with the department of human services, shall adopt rules which address, but are not limited to addressing, all of the following:
a. Implementation and administration of the program.
b. The program application form. The form shall include a request for information regarding other health insurance coverage for each child.
c. Criteria for the selection of an administrative contractor for the program.
d. Qualifying standards for selecting participating insurers for the program.
e. The benefits to be included in a qualified child health plan which are those included in a benchmark or benchmark equivalent plan and which comply with Title XXI of the federal Social Security Act. Benefits covered shall include but are not limited to all of the following:
(1) Inpatient hospital services including medical, surgical, intensive care unit, mental health, and substance abuse services.
(2) Nursing care services including skilled nursing facility services.
(3) Outpatient hospital services including emergency room, surgery, lab, and x-ray services and other services.
(4) Physician services, including surgical and medical, and including office visits, newborn care, well-baby and well- child care, immunizations, urgent care, specialist care, allergy testing and treatment, mental health visits, and substance abuse visits.
(5) Ambulance services.
(6) Physical therapy.
(7) Speech therapy.
(8) Durable medical equipment.
(9) Home health care.
(10) Hospice services.
(11) Prescription drugs.
(12) Dental services including preventive services.
(13) Medically necessary hearing services.
(14) Vision services including corrective lenses.
f. Standards for program eligibility. The standards shall not discriminate on the basis of diagnosis. Within a defined group of covered eligible children, the standards shall not cover children of higher income families without covering children of families with lower incomes. The standards shall not deny eligibility based on a child having a preexisting medical condition.
g. Presumptive eligibility criteria for the program.
h. The amount of any cost sharing under the program which shall be assessed on a sliding fee scale based on family income, which provides for a minimum amount of cost sharing, and which complies with federal law.
i. The reasons for disenrollment including, but not limited to, nonpayment of premiums, eligibility for medical assistance or other insurance coverage, admission to a public institution, relocation from the area, and change in income.
j. Conflict of interest provisions applicable to the administrative contractor and participating insurers, and between public members of the board and the administrative contractor and participating insurers.
k. Penalties for breach of contract or other violations of requirements or provisions under the program.
l. A mechanism for participating insurers to report any rebates received to the department.
m. The reasons allowed for approval of an application in cases in which prior employer-sponsored coverage ended less than six months prior to the determination of eligibility for the HAWK-I program. The reasons established by rule shall include, but are not limited to, all of the following:
(1) Loss of employment due to factors other than voluntary termination.
(2) Death of a parent.
(3) Change in employment to a new employer that does not provide an option for dependent coverage.
(4) Change of address so that no employer-sponsored coverage is available.
(5) Discontinuation of health benefits to all employees of the applicant's employer.
(6) Expiration of the coverage periods established by the federal Consolidated Omnibus Budget Reconciliation Act of 1986, Pub. L. No. 99-272, as amended.
(7) Self-employment.
(8) Termination of health benefits due to a long-term disability.
(9) Termination of dependent coverage due to an extreme economic hardship on the part of either the employee or the employer, as determined by rule.
(10) Substantial reduction in either lifetime medical benefits or benefit category available to an employee and dependents under an employer's health care plan.
If the board determines that the allowance of the six-month period from the time of dropping coverage to be eligible for participation in the HAWK-I program is insufficient to effectively deter applicants or employers of applicants from discontinuing employer-sponsored dependent care coverage for the purpose of participation in the HAWK-I program, the board may adopt rules to extend the time period to a period not to exceed twelve months.
n. The data to be maintained by the administrative contractor including data to be collected for the purposes of quality assurance reports.
98 Acts, ch 1196, §6, 16
Appointment and commencement of duties of initial board members; 98 Acts, ch 1196, § 12
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