441—86.1 (514I) Definitions.
“Applicant” shall mean all parents, spouses, and children under the age of 19 who are counted in the HAWK-I family size and who are listed on the application or renewal form.
“Benchmark benefit package” shall mean any of the following:
	  1. 	 The standard Blue Cross Blue Shield preferred provider option service benefit plan, described in and offered under 5 U.S.C. Section 8903(1).
	  2. 	 A health benefits coverage plan that is offered and generally available to state employees in this state.
	  3. 	 The plan of a health maintenance organization, as defined in 42 U.S.C. Section 300e, with the largest insured commercial, nonmedical assistance enrollment of covered lives in the state.
“Capitation rate” shall mean the fee the department pays monthly to a participating health plan for each enrollee for the provision of covered medical services whether or not the enrollee received services during the month for which the fee is intended.
“Contract” shall mean the contract between the department and the person or entity selected as the third-party administrator or the contract between the department and the participating health plan for the provision of medical services to HAWK-I enrollees for whom the participating health plans assume risk.
“Cost sharing” shall mean the payment of a premium or copayment as provided for by Title XXI of the federal Social Security Act and Iowa Code section 514I.10.
“Covered services” shall mean all or a part of those medical and health services set forth in rule 441—86.14(514I).
“Department” shall mean the Iowa department of human services.
“Director” shall mean the director of the Iowa department of human services.
“Earned income” means the earned income of all parents, spouses, and children under the age of 19 who are not students who are living together in accordance with subrule 86.2(3). Income shall be countable earned income when a person produces it as a result of the performance of services. “Earned income” includes:
	  1. 	 All income in the form of a salary, wages, tips, bonuses, and commissions earned as an employee, and
	  2. 	 The net profit from self-employment determined by comparing gross income produced from self-employment with the allowable costs of producing the income. The allowable costs of producing self-employment income shall be determined by the costs allowed for income tax purposes. Additionally, the cost of depreciation of capital assets identified for income tax purposes shall be allowed as a cost of doing business for self-employed persons. Losses from a self-employment enterprise may not be used to offset income from any other source.
“Eligible child” shall mean an individual who meets the criteria for participation in the HAWK-I program as set forth in rule 441—86.2(514I).
“Emergency medical condition” shall mean a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in one of the following:
	  1. 	 Placing the health of the person or, with respect to a pregnant woman, the health of the woman and her unborn child, in serious jeopardy,
	  2. 	 Serious impairment to bodily functions, or
	  3. 	 Serious dysfunction of any bodily organ or part.
“Emergency services” shall mean, with respect to an individual enrolled with a plan, covered inpatient and outpatient services which are furnished by a provider qualified to furnish these services and which are needed to evaluate and stabilize an emergency medical condition.
“Enrollee” shall mean a child who has been determined eligible for the program and who has been enrolled with a participating health plan.
“Family” shall mean all parents, spouses, and children under the age of 19 who are counted in the HAWK-I family size.
“Federal poverty level” shall mean the poverty income guidelines revised annually and published in the Federal Register by the United States Department of Health and Human Services.
“Good cause” shall mean the family has demonstrated that one or more of the following conditions exist:
	  1. 	 There was a serious illness or death of the enrollee or a member of the enrollee’s family.
	  2. 	 There was a family emergency or household disaster, such as a fire, flood, or tornado.
	  3. 	 There was a reason beyond the enrollee’s control.
	  4. 	 There was a failure to receive the third-party administrator’s request for a reason not attributable to the enrollee. Lack of a forwarding address is attributable to the enrollee.
“Gross countable income” means gross income minus exemptions permitted by paragraph 86.2(2)“b.”
“Gross income” means a combination of the following:
	  1. 	 Earned income,
	  2. 	 Unearned income, and
	  3. 	 Recurring lump-sum income prorated over the time the income is intended to cover.
“HAWK-I board”  or “board”  shall mean the entity that adopts rules, establishes policy, and directs the department regarding the HAWK-I program.
“HAWK-I program”  or “program”  shall mean the healthy and well kids in Iowa program implemented in this chapter to provide health care coverage to eligible children.
“Health insurance coverage” shall mean health insurance coverage as defined in 42 U.S.C. Section 300gg(c).
“Institution for mental diseases” shall mean a hospital, nursing facility, or other institution of more than 16 beds that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care and related services as defined at 42 CFR Section 435.1009 as amended November 10, l994.
“Nonmedical public institution” shall mean an institution that is the responsibility of a governmental unit or over which a governmental unit exercises administrative control as defined in 42 CFR Section 435.1009 as amended November 10, l994.
“Participating health plan” shall mean any entity licensed by the division of insurance of the department of commerce to provide health insurance in Iowa or an organized delivery system licensed by the director of public health that has contracted with the department to provide health insurance coverage to eligible children under this chapter.
“Physician” shall be defined as provided in Iowa Code subsection 135.1(4).
“Provider” shall mean an individual, firm, corporation, association, or institution that is providing or has been approved to provide medical care or services to an enrollee pursuant to the HAWK-I program.
“Recurring lump-sum income” means earned and unearned lump-sum income that is received on a regular basis. These payments may include, but are not limited to:
	  1. 	 Annual bonuses.
	  2. 	 Lottery winnings that are paid out annually.
“Regions” shall mean the six regions of the state as follows:
	  ● 	 Region 1: Lyon, Osceola, Dickinson, Emmet, Sioux, O’Brien, Clay, Palo Alto, Plymouth, Cherokee, Buena Vista, Woodbury, Ida, Sac, Monona, Crawford, and Carroll.
	  ● 	 Region 2: Kossuth, Winnebago, Worth, Mitchell, Howard, Hancock, Cerro Gordo, Floyd, Pocahontas, Humboldt, Wright, Franklin, Calhoun, Webster, Hamilton, Hardin, Greene, Boone, Story, Marshall, and Tama.
	  ● 	 Region 3: Winneshiek, Allamakee, Chickasaw, Fayette, Clayton, Butler, Bremer, Grundy, Black Hawk, Buchanan, Delaware, Dubuque, Jones, Jackson, Cedar, Clinton, and Scott.
	  ● 	 Region 4: Harrison, Shelby, Audubon, Pottawattamie, Cass, Mills, Montgomery, Fremont, and Page.
	  ● 	 Region 5: Guthrie, Dallas, Polk, Jasper, Adair, Madison, Warren, Marion, Adams, Union, Clarke, Lucas, Taylor, Ringgold, Decatur, and Wayne.
	  ● 	 Region 6: Benton, Linn, Poweshiek, Iowa, Johnson, Muscatine, Mahaska, Keokuk, Washington, Louisa, Monroe, Wapello, Jefferson, Henry, Des Moines, Appanoose, Davis, Van Buren, and Lee.
“Self-employed” means that a person satisfies any of the following conditions:
	  1. 	 The person is not required to report to the office regularly except for specific purposes such as sales training meetings, administrative meetings, or evaluation sessions; or
	  2. 	 The person establishes the person’s own working hours, territory, and methods of work; or
	  3. 	 The person files quarterly reports of earnings, withholding payments, and FICA payments to the Internal Revenue Service.
“Third-party administrator” shall mean the person or entity with which the department contracts to provide administrative services for the HAWK-I program.
“Unearned income” means cash income of all parents, spouses, and children under the age of 19 who are living together in accordance with subrule 86.2(3) that is not gained by labor or service. The available unearned income shall be the amount remaining after the withholding of taxes (Federal Insurance Contribution Act, state and federal income taxes). Examples of unearned income include, but are not limited to:
	  1. 	 Social security benefits, meaning the amount of the entitlement before withholding of a Medicare premium.
	  2. 	 Child support and alimony payments received for a member of the family.
	  3. 	 Unemployment compensation.
	  4. 	 Veterans benefits.
[ARC 7770B, IAB 5/20/09, effective 7/1/09]