441—86.8 (514I) Premiums and copayments.
	 86.8(1) Income considered. The countable income considered in determining the premium amount shall be the family’s gross countable income minus 20 percent of the family’s earned income.
	 86.8(2) Premium amount. Except as specified for supplemental dental-only coverage in subrule 86.20(4), 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 150 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 150 percent of the federal poverty level for a family of the same size but does not exceed 200 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 200 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 tenth 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 tenth 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 tenth 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. Failure to pay the premium by the last day of the month before the month of coverage shall result in cancellation from the program. Premiums may be paid in advance (e.g., on a quarterly or semiannual basis) rather than a monthly basis.
	 86.8(4) Reinstatement. A child may be reinstated once per enrollment period when the family fails to pay the premium by the last day of the month for the next month’s coverage. If the premium is subsequently received, coverage will be reinstated if the premium was postmarked or otherwise paid in the calendar month immediately following disenrollment.
	 86.8(5) Method of premium payment. Premiums may be submitted in the form of cash, personal checks, automatic bank account withdrawals, 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 reinstatement 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.
[ARC 7770B, IAB 5/20/09, effective 7/1/09; ARC 8478B, IAB 1/13/10, effective 3/1/10]