36-2982

36-2982. Children's health insurance program;
administration; nonentitlement; enrollment limitation;
eligibility

A. The children's health insurance program is established for children who are
eligible pursuant to section 36-2981, paragraph 6. The administration shall administer
the program. All covered services shall be provided by health plans that have contracts
with the administration pursuant to section 36-2906, by a qualifying plan or by either
tribal facilities or the Indian health service for Native Americans who are eligible for
the program and who elect to receive services through the Indian health service or a
tribal facility.

B. This article does not create a legal entitlement for any applicant or member who
is eligible for the program. Total enrollment is limited based on the annual
appropriations made by the legislature and the enrollment cap prescribed in section
36-2985.

C. The director shall take all steps necessary to implement the administrative
structure for the program and to begin delivering services to persons within sixty days
after approval of the state plan by the United States department of health and human
services.

D. The administration shall perform eligibility determinations for persons applying
for eligibility and annual redeterminations for continued eligibility pursuant to this
article.

E. The administration shall adopt rules for the collection of copayments from
members whose income does not exceed one hundred fifty per cent of the federal poverty
level and for the collection of copayments and premiums from members whose income exceeds
one hundred fifty per cent of the federal poverty level. The director shall adopt rules
for disenrolling a member if the member does not pay the premium required pursuant to
this section. The director shall adopt rules to prescribe the circumstances under which
the administration shall grant a hardship exemption to the disenrollment requirements of
this subsection for a member who is no longer able to pay the premium.

F. Before enrollment, a member, or if the member is a minor, that member's parent
or legal guardian, shall select an available health plan in the member's geographic
service area or a qualifying health plan offered in the county, and may select a primary
care physician or primary care practitioner from among the available physicians and
practitioners participating with the contractor in which the member is enrolled. The
contractors shall only reimburse costs of services or related services provided by or
under referral from a primary care physician or primary care practitioner participating
in the contract in which the member is enrolled, except for emergency services that shall
be reimbursed pursuant to section 36-2987. The director shall establish requirements as
to the minimum time period that a member is assigned to specific contractors.

G. Eligibility for the program is creditable coverage as defined in section
20-1379.

H. On application for eligibility for the program, the member, or if the member is
a minor, the member's parent or guardian, shall receive an application for and a program
description of the premium sharing program.

I. Notwithstanding section 36-2983, the administration may purchase for a member
employer sponsored group health insurance with state and federal monies available
pursuant to this article, subject to any restrictions imposed by the federal health care
financing administration. This subsection does not apply to members who are eligible for
health benefits coverage under a state health benefits plan based on a family member's
employment with a public agency in this state.