Iowa Admin. Code r. 441-86.2

Current through Register Vol. 46, No. 19, March 20, 2024

Rule 441-86.2 - Eligibility factors

The decision with respect to eligibility shall be based primarily on electronic data matches and information furnished by the applicant, the enrollee, or a person acting on behalf of the applicant or enrollee. A child must meet the following eligibility factors to participate in the hawki program.

(1)Age. The child shall be under 19 years of age. Eligibility for the program ends the first day of the month following the month of the child's nineteenth birthday.

(2)Income.

a.Countable income. In determining initial and ongoing eligibility for the hawki program, countable income shall not exceed 302 percent of the federal poverty level for a family of the same size. Countable income shall be determined using the modified adjusted gross income methodology.

b.Verification of income. Income shall be verified through electronic data matches when possible or otherwise verified using the best information available.

(1) Pay stubs, tip records, tax records and employers' statements are acceptable forms of verification of earned income.

(2) If self-employment income cannot be verified through electronic means, business records or income tax returns from the previous year can be used if they are representative of anticipated earnings. If business records or tax returns from the previous year are not representative of anticipated earnings, an average of the business records or tax returns from the previous two or three years may be used if that average is representative of anticipated earnings.

c.Changes in income. Once initial eligibility is established, changes in income during the 12-month enrollment period shall not affect the child's eligibility to participate in the hawki program. However, if income has decreased, the family may request a review of their income to establish whether they are required to continue paying a premium in accordance with rule 441-86.8 (5141).

(3)Family size. For purposes of establishing initial and ongoing eligibility under the hawki program, the family size shall be determined according to the modified adjusted gross income methodology.

(4)Uninsured status. The child must be uninsured.

a. A child who is currently enrolled in an individual or group health plan is not eligible to participate in the hawki program. However, a child who is enrolled in a plan shall not be considered insured for purposes of the hawki program if:

(1) The plan provides coverage only for a specific disease or service (such as a vision, dental, or cancer policy), or

(2) The child does not have reasonable geographic access to care under that plan. "Reasonable geographic access" means that the plan or an option available under the plan does not have service area limitations or, if the plan has service area limitations, the child lives within 30 miles or 30 minutes of a network primary care provider, or

(3) The child lost Medicaid eligibility solely because of the loss of income disregards from the implementation of the modified adjusted gross income methodology. If a child loses eligibility because of such loss of income disregards, the child may be covered under the hawki program for up to 12 months following the loss of Medicaid eligibility regardless of the presence of other health insurance.

b. A child whose health insurance ends in the month of application shall be considered uninsured for purposes of hawki eligibility. However, a one-month waiting period may be imposed pursuant to subrule 86.5(1) for a child who is subject to a monthly premium pursuant to paragraph 86.8(2)"c. "

c. American Indian and Alaska Native. American Indian and Alaska Native children are eligible for the hawki program on the same basis as other children in the state, regardless of whether or not they may be eligible for or served by Indian Health Services-funded care.

(5)Ineligibility for Medicaid. The child shall not be receiving Medicaid or eligible to receive Medicaid except when the child would be required to meet a spenddown under the medically needy program in accordance with the provisions of 441-subrule 75.1(35).

(6)Iowa residency. Residency in Iowa is a condition of eligibility for the hawki program. Residency shall be established in accordance with rule 441-75.10(249A).

(7)Citizenship and immigration status. To be eligible for the hawki program, the child shall be a citizen or lawfully admitted immigrant. The criteria established under 441-subrule 75.11(2) shall be followed when determining whether a lawfully admitted immigrant child is eligible to participate in the hawki program.

a. The citizenship or immigration status of the parents or other responsible person shall not be considered when determining the eligibility of the child to participate in the program.

b. As a condition of eligibility for hawki:

(1) All applicants shall attest to their citizenship status by signing the application form, which contains a citizenship declaration.

(2) When a child under the age of 19 is not living independently, the child's parent or other responsible person with whom the child lives shall be responsible for attesting to the child's citizenship or immigration status and for providing any required proof of the status.

c. Except as provided in 441-paragraph 75.11(2)'^" applicants or enrollees for whom an attestation of United States citizenship has been made pursuant to paragraph 86.2(7)"b" shall present satisfactory documentation of citizenship or nationality as defined in 441-paragraphs 75.11(2) "d,""e,""g,""h," and "i."

d. An applicant or enrollee shall have a reasonable opportunity period to obtain and provide proof of citizenship and nationality in accordance with 441-paragraph 75.11(2)"c."

e. Failure to provide acceptable documentary evidence for a child shall not affect the eligibility of other children in the family for whom acceptable documentary evidence has been provided.

(8)Dependents of state of Iowa employees. The child shall not be eligible for the hawki program if the child is eligible for health insurance coverage as a dependent of a state of Iowa employee unless the state contributes only a nominal amount toward the cost of dependent coverage. "Nominal amount" shall mean $10 or less per month.

(9)Inmates of public institutions. The child shall not be an inmate of a public institution as defined at 42 CFR Section 435.1010.

(10)Inmates of institutions for mental disease. At the time of application or annual review of eligibility, the child shall not be an inmate of an institution for mental disease as defined at 42 CFR Section 435.1010.

(11)Furnishing a social security number. As a condition of eligibility and in accordance with rule 441-75.7(249A), a social security number or proof of application for the number if the number has not been issued or is not known must be furnished for a child for whom coverage under hawki is being requested or received.

Iowa Admin. Code r. 441-86.2

ARC 7770B, IAB 5/20/09, effective 7/1/09; ARC 7881B, IAB 7/1/09, effective 7/1/09; ARC 8109B, IAB 9/9/09, effective 10/14/09; ARC 8127B, IAB 9/9/09, effective 9/1/09; ARC 8280B, IAB 11/18/09, effective 1/1/10; ARC 8281B, IAB 11/18/09, effective 12/23/09; ARC 8478B, IAB 1/13/10, effective 3/1/10; ARC 8838B, IAB 6/16/10, effective 6/1/10; ARC 9083B, IAB 9/22/10, effective 9/1/10; ARC 0837C, IAB 7/24/2013, effective 10/1/2013; ARC 1287C, IAB 1/8/2014, effective 1/1/2014

Amended by IAB August 12, 2020/Volume XLIII, Number 4, effective 12/1/2020