Iowa Admin. Code r. 441-75.1 - Persons covered
(1)
Persons receiving refugee cash assistance. Medical assistance
shall be available to all recipients of refugee cash assistance. Recipient
means a person for whom a refugee cash assistance (RCA) payment is received and
includes persons deemed to be receiving RCA. Persons deemed to be receiving RCA
are:
a. Persons denied RCA because the amount
of payment would be less than $10.
b. Rescinded IAB 7/30/08, effective
10/1/08.
c. Persons who are
eligible in every respect for refugee cash assistance (RCA) as provided in
441-Chapter 60, but who do not receive RCA because they did not make
application for the assistance.
(2) Rescinded IAB 10/8/97, effective
12/1/97.
(3)
Persons who
are ineligible for Supplemental Security Income (SSI) because of requirements
that do not apply under Title XIX of the Social Security Act. Medicaid
shall be available to persons who would be eligible for SSI except for an
eligibility requirement used in that program which is specifically prohibited
under Title XIX.
(4)
Beneficiaries of Title XVI of the Social Security Act (supplemental
security income for the aged , blind and disabled ) and mandatory state
supplementation. Medical assistance will be available to all
beneficiaries of the Title XVI program and those receiving mandatory state
supplementation.
(5)
Persons receiving care in a medical institution who were eligible for
Medicaid as of December 31, 1973. Medicaid shall be available to all
persons receiving care in a medical institution who were Medicaid members as of
December 31, 1973. Eligibility of these persons will continue as long as they
continue to meet the eligibility requirements for the applicable assistance
programs (old-age assistance, aid to the blind or aid to the disabled ) in
effect on December 31, 1973.
(6)
Persons who would be eligible for supplemental security income (SSI),
state supplementary assistance (SSA), or the family medical assistance program
(FMAP) except for their institutional status. Medicaid shall be
available to persons receiving care in a medical institution who would be
eligible for SSI, SSA, or FMAP if they were not institutionalized.
(7)
Persons receiving care in a
medical facility who would be eligible under a special income
standard.
a. Subject to
paragraphs"b " and"c " below, Medicaid shall
be available to persons who:
(1) Meet level
of care requirements as set forth in rules
441-78.3 (249A),
441-81.3 (249A), and
441-82.7(249A).
(2) Receive care in
a hospital, nursing facility, psychiatric medical institution , intermediate
care facility for the mentally retarded, or Medicare-certified skilled nursing
facility.
(3) Have gross countable
monthly income that does not exceed 300 percent of the federal supplemental
security income benefits for one.
(4) Either meet all supplemental security
income (SSI) eligibility requirements except for income or are under age 21.
FMAP policies regarding income and age do not apply when determining
eligibility for persons under the age of 21.
b. For all persons in this coverage group ,
income shall be considered as provided for SSI-related coverage groups under
subrule 75.13(2). In establishing eligibility for persons aged 21 or older for
this coverage group , resources shall be considered as provided for SSI-related
coverage groups under subrule 75.13(2).
c. Eligibility for persons in this group
shall not exist until the person has been institutionalized for a period of 30
consecutive days and shall be effective no earlier than the first day of the
month in which the 30-day period begins. A "period of 30 days" is defined as
being from 12 a.m. of the day of admission to the medical institution , and
ending no earlier than 12 midnight of the thirtieth day following the beginning
of the period.
(1) A person who enters a
medical institution and who dies prior to completion of the 30-day period shall
be considered to meet the 30-day period provision.
(2) Only one 30-day period is required to
establish eligibility during a continuous stay in a medical institution .
Discharge during a subsequent month, creating a partial month of care, does not
affect eligibility for that partial month regardless of whether the eligibility
determination was completed prior to discharge.
(3) A temporary absence of not more than 14
full consecutive days during which the person remains under the jurisdiction of
the institution does not interrupt the 30-day period. In order to remain "under
the jurisdiction of the institution" a person must first have been physically
admitted to the institution.
(8)
Certain persons essential to the
welfare of Title XVI beneficiaries. Medical assistance will be
available to the person living with and essential to the welfare of a Title XIX
beneficiary provided the essential person was eligible for medical assistance
as of December 31, 1973. The person will continue to be eligible for medical
assistance as long as the person continues to meet the definition of "essential
person" in effect in the public assistance program on December 31,
1973.
(9)
Individuals
receiving state supplemental assistance. Medical assistance shall be
available to all recipients of state supplemental assistance as authorized by
Iowa Code chapter 249.
(10)
Individuals under age 21 living in a licensed foster care facility or
in a private home pursuant to a subsidized adoption arrangement for whom the
department has financial responsibility in whole or in part. When Iowa
is responsible for foster care payment for a child pursuant to Iowa Code
section
234.35
and rule 441-156.20 (234) or has
negotiated an adoption assistance agreement for a child pursuant to rule
441-201.5 (600), medical
assistance shall be available to the child if:
a. The child lives in Iowa and is not
otherwise eligible under a category for which federal financial participation
is available; or
(11)
Individuals living in
a court-approved subsidized guardianship home for whom the department has
financial responsibility in whole or in part. When Iowa is responsible
for a subsidized guardianship payment for a child pursuant to 441-Chapter 204,
medical assistance will be available to the child under this subrule if the
child is living in a court-approved subsidized guardianship home and either:
a. The child lives in Iowa and is not
eligible for medical assistance under a category for which federal financial
participation is available due to reasons other than:
(1) Failure to provide information,
or
(2) Failure to comply with other
procedural requirements; or
b. Notwithstanding the residency requirements
of 441-75.10 (249A) and
441-75.53 (249A), the child
lives in another state and is not eligible for benefits from the other state
pursuant to a program funded under Title XIX of the federal Social Security Act
due to reasons other than:
(1) Failure to
provide information, or
(2) Failure
to comply with other procedural requirements.
(12)
Persons ineligible due to
October 1, 1972, social security increase. Medical assistance will be
available to individuals and families whose assistance grants were canceled as
a result of the increase in social security benefits October 1, 1972, as long
as these individuals and families would be eligible for an assistance grant if
the increase were not considered.
(13)
Persons who would be eligible
for supplemental security income or state supplementary assistance but for
social security cost-of-living increases received. Medical assistance
shall be available to all current social security recipients who meet the
following conditions:
a. They were entitled to
and received concurrently in any month after April 1977 supplemental security
income and social security or state supplementary assistance and social
security, and
b. They subsequently
lost eligibility for supplemental security income or state supplementary
assistance, and
c. They would be
eligible for supplemental security income or state supplementary assistance if
all of the social security cost-of-living increases which they and their
financially responsible spouses, parents, and dependent children received since
they were last eligible for and received social security and supplemental
security income (or state supplementary assistance) concurrently were deducted
from their income. Spouses, parents, and dependent children are considered
financially responsible if their income would be considered in determining the
applicant 's eligibility.
(14)
Family medical assistance
program (FMAP). Medicaid shall be available to children who meet the
provisions of rule 441-75.54 (249A) and to the
children's specified relatives who meet the provisions of subrule 75.54(2) and
rule 441-75.55 (249A) if the
following criteria are met.
a. In establishing
eligibility of specified relatives for this coverage group , resources are
considered in accordance with the provisions of rule
441-75.56 (249A) and shall not
exceed $2,000 for applicant households or $5,000 for member households. In
establishing eligibility for children for this coverage group , resources of all
persons in the eligible group, regardless of age, shall be
disregarded.
b. Income is
considered in accordance with rule
441-75.57 (249A) and does not
exceed needs standards established in rule
441-75.58 (249A).
c. Rescinded IAB 11/1/00, effective
1/1/01.
(15)
Child medical assistance program (CMAP). Medicaid shall be
available to persons under the age of 21 if the following criteria are met:
a. Financial eligibility shall be determined
for the family size of which the child is a member using the income standards
in effect for the family medical assistance program (FMAP) unless otherwise
specified. Income shall be considered as provided in rule
441-75.57 (249A). Additionally,
the earned income disregards as provided in paragraphs 75.57(2)"a, "
"b, " "c, " and"d" shall be allowed for those persons
whose income is considered in establishing eligibility for the persons under
the age of 21 and whose needs must be included in accordance with paragraph
75.58(1)"a" but who are not eligible for Medicaid. Resources of all persons in
the eligible group, regardless of age, shall be disregarded. Unless a family
member is voluntarily excluded in accordance with the provisions of rule
441-75.59 (249A), family size
shall be determined as follows:
(1) If the
person under the age of 21 is pregnant and the pregnancy has been verified in
accordance with rule 441-75.17 (249A), the unborn
child (or children if more than one) is considered a member of the family for
purposes of establishing the number of persons in the family.
(2) A "man-in-the-house" who is not married
to the mother of the unborn child is not considered a member of the unborn
child 's family for the purpose of establishing the number of persons in the
family. His income and resources are not automatically considered, regardless
of whether or not he is the legal or natural father of the unborn child .
However, income and resources made available to the mother of the unborn child
by the "man-in-the-house" shall be considered in determining eligibility for
the pregnant individual.
(3) Unless
otherwise specified, when the person under the age of 21 is living with a
parent (s), the family size shall consist of all family members as defined by
the family medical assistance program in accordance with paragraph
75.57(8)"c" and subrule 75.58(1).
Application for Medicaid shall be made by the
(4) When a person is living with a spouse the
family size shall consist of that person, the spouse and any of their children,
including any unborn children.
(5)
Siblings under the age of 21 who live together shall be considered in the same
filing unit for the purpose of establishing eligibility under this rule unless
one sibling is married or has been married, in which case, the married sibling
shall be considered separately unless the marriage was annulled.
(6) When a person is residing in a household
in which some members are receiving FMAP under the provisions of subrule
75.1(14) or MAC under the provisions of subrule 75.1(28), and when the person
is not included in the FMAP or MAC eligible group, the family size shall
consist of the person and all other family members as defined above except
those in the FMAP or MAC eligible group.
b. Rescinded IAB 9/6/89, effective
11/1/89.
c. Rescinded IAB 11/1/89,
effective 1/1/90.
d. A person is
eligible for the entire month in which the person's twenty-first birthday
occurs unless the birthday falls on the first day of the month.
e. Living with a specified relative as
provided in subrule 75.54(2) shall not be considered when determining
eligibility for persons under this coverage group .
(16)
Children receiving subsidized
adoption payments from states providing reciprocal medical assistance
benefits. Medical assistance shall be available to children under the
age of 21 for whom an adoption assistance agreement with another state is in
effect if all of the following conditions are met:
a. The child is residing in Iowa in a private
home with the child's adoptive parent or parents.
b. Benefits funded under Title IV-E of the
Social Security Act are not being paid for the child by any state.
c. Another state currently has an adoption
assistance agreement in effect for the child.
d. The state with the adoption assistance
agreement:
(1) Is a member of the interstate
compact on adoption and medical assistance (ICAMA); and
(2) Provides medical assistance benefits
pursuant to a program funded under Title XIX of the Social Security Act, under
the optional group at Section 1902(a)(10)(A)(ii)(VIII) of the Act, to children
residing in that state (at least until age 18) for whom there is a state
adoption assistance agreement in effect with the state of Iowa other than under
Title IV-E of the Social Security Act.
(17)
Persons who meet the income and
resource requirements of the cash assistance programs. Medicaid shall
be available to the following persons who meet the income and resource
guidelines of supplemental security income or refugee cash assistance, but who
are not receiving cash assistance:
a. Aged and
blind persons, as defined at subrule 75.13(2).
b. Disabled persons, as defined at rule
441-75.20 (249A).
In establishing eligibility for children for this
(18)
Persons eligible for waiver services. Medicaid shall be
available to recipients of waiver services as defined in 441-Chapter
83.
(19)
Persons and
families terminated from aid to dependent children (ADC) prior to April 1,
1990, due to discontinuance of the $30 or the $30 and one-third earned income
disregards. Rescinded IAB 6/12/91, effective 8/1/91.
(20)
Newborn children.
Medicaid shall be available without an application to newborn children of women
who are determined eligible for Medicaid for the month of the child's birth or
for three-day emergency services for labor and delivery for the child's birth.
Effective April 1, 2009, eligibility begins with the month of the birth and
continues through the month of the first birthday as long as the child remains
an Iowa resident.
a. The department shall
accept any written or verbal statement as verification of the newborn's birth
date unless the birth date is questionable.
b. In order for Medicaid to continue after
the month of the first birthday, a redetermination of eligibility shall be
completed.
(21)
Persons and families ineligible for the family medical assistance
program (FMAP) in whole or in part because of child or spousal
support. Medicaid shall be available for an additional four months to
persons and families who become ineligible for FMAP because of income from
child support, alimony, or contributions from a spouse if the person or family
member received FMAP in at least three of the six months immediately preceding
the month of cancellation.
a. The four months
of extended Medicaid coverage begin the day following termination of FMAP
eligibility.
b. When ineligibility
is determined to occur retroactively, the extended Medicaid coverage begins
with the first month in which FMAP eligibility was erroneously
granted.
c. Rescinded IAB 10/11/95,
effective 10/1/95.
(22)
Refugee spend down participants. Rescinded IAB 10/11/95,
effective 10/1/95.
(23)
Persons who would be eligible for supplemental security income or state
supplementary assistance but for increases in social security benefits because
of elimination of the actuarial reduction formula and cost-of-living increases
received. Medical assistance shall be available to all current social
security recipients who meet the following conditions. They:
a. Were eligible for a social security
benefit in December of 1983.
b.
Were eligible for and received a widow's or widower's disability benefit and
supplemental security income or state supplementary assistance for January of
1984.
c. Became ineligible for
supplemental security income or state supplementary assistance because of an
increase in their widow's or widower's benefit which resulted from the
elimination of the reduction factor in the first month in which the increase
was paid and in which a retroactive payment of that increase for prior months
was not made.
d. Have been
continuously eligible for a widow's or widower's benefit from the first month
the increase was received.
e. Would
be eligible for supplemental security income or state supplementary assistance
benefits if the amount of the increase from elimination of the reduction factor
and any subsequent cost-of-living adjustments were disregarded.
f. Submit an application prior to July 1,
1988, on Form 470-0442, Application for Medical Assistance or State
Supplementary Assistance.
(24)
Postpartum eligibility for
pregnant women. Medicaid shall continue to be available, without an
application, for 60 days beginning with the last day of pregnancy and
throughout the remaining days of the month in which the 60-day period ends, to
a woman who had applied for Medicaid prior to the end of her pregnancy and was
subsequently determined eligible for Medicaid for the month in which the
pregnancy ended.
a. Postpartum Medicaid shall
only be available to a woman who is not eligible for another coverage group
after the pregnancy ends.
b. The
woman shall not be required to meet any income or resource criteria during the
postpartum period.
c. When the
sixtieth day is not on the last day of the month the woman shall be eligible
for Medicaid for the entire month.
(25)
Persons who would be eligible
for supplemental security income or state supplementary assistance except that
they receive child's social security benefits based on disability.
Medical assistance shall be available to persons who receive supplemental
security income (SSI) or state supplementary assistance (SSA) after their
eighteenth birthday because of a disability or blindness which began before age
22 and who would continue to receive SSI or SSA except that they become
entitled to or receive an increase in social security benefits from a parent 's
account.
(26) Rescinded IAB
10/8/97, effective 12/1/97.
(27)Widows and widowers who are no
longer eligible for supplemental security income or state supplementary
assistance because of the receipt of social security benefits.
Medicaid shall be available to widows and widowers who meet the following
conditions:
a. They have applied for and
received or were considered recipients of supplemental security income or state
supplementary assistance.
b. They
apply for and receive Title II widow's or widower's insurance benefits or any
other Title II old age or survivor's benefits, if eligible for widow's or
widower's benefits.
c. Rescinded
IAB 5/1/91, effective 4/11/91.
d.
They were not entitled to Part A Medicare hospital insurance benefits at the
time of application and receipt of Title II old age or survivor's benefits.
They are not currently entitled to Part A Medicare hospital insurance
benefits.
e. They are no longer
eligible for supplemental security income or state supplementary assistance
solely because of the receipt of their social security benefits.
(28)
Pregnant women,
infants and children (Mothers and Children (MAC)). Medicaid shall be
available to all pregnant women, infants (under one year of age) and children
who have not attained the age of 19 if the following criteria are met:
a. Income.
(1) Family income shall not exceed 300
percent of the federal poverty level for pregnant women and for infants (under
one year of age). Family income shall not exceed 133 percent of the federal
poverty level for children who have attained one year of age but who have not
attained 19 years of age. Income to be considered in determining eligibility
for pregnant women, infants, and children shall be determined according to
family medical assistance program (FMAP) methodologies except that the
three-step process for determining initial eligibility and the two-step process
for determining ongoing eligibility , as described at rule
441-75.57 (249A), shall not
apply. "Family income" is the income remaining after disregards and deductions
have been applied as provided in rule
441-75.57 (249A).
(2) Moneys received as a lump sum, except as
specified in subrules 75.56(4) and 75.56(7) and paragraphs 75.57(8)"b
" and"c, " shall be treated in accordance with
paragraphs 75.57(9)"b " and"c. "
(3) Unless otherwise specified, when the
person under the age of 19 is living with a parent or parents, the family size
shall consist of all family members as defined by the family medical assistance
program.
Application for Medicaid shall be made by the parents when
the person is residing with them. A person shall be considered to be living
with the parents when the person is temporarily absent from the
(4) When a person under the age of 19 is
living with a spouse, the family size shall consist of that person, the spouse,
and any of their children.
(5)
Siblings under the age of 19 who live together shall be considered in the same
filing unit for the purpose of establishing eligibility under this subrule
unless one sibling is married or has been married, in which case the married
sibling shall be considered separately unless the marriage was
annulled.
b. For
pregnant women, resources shall not exceed $10,000 per household. In
establishing eligibility for infants and children for this coverage group ,
resources of all persons in the eligible group, regardless of age, shall be
disregarded. In establishing eligibility for pregnant women for this coverage
group , resources shall be considered in accordance with department of public
health 641-subrule 75.4(2).
c.
Rescinded IAB 9/6/89, effective 11/1/89.
d. Eligibility for pregnant women under this
rule shall begin no earlier than the first day of the month in which conception
occurred and in accordance with 441-76.5(249A).
e. The unborn child (children if more than
one fetus exists) shall be considered when determining the number of persons in
the household.
f. An infant shall
be eligible through the month of the first birthday unless the birthday falls
on the first day of the month. A child shall be eligible through the month of
the nineteenth birthday unless the birthday falls on the first day of the
month.
g. Rescinded IAB 11/1/89,
effective 1/1/90.
h. When
determining eligibility under this coverage group , living with a specified
relative as specified at subrule 75.54(2) and the student provisions specified
in subrule 75.54(1) do not apply.
i. A woman who had applied for Medicaid prior
to the end of her pregnancy and was subsequently determined eligible for
assistance under this coverage group for the month in which her pregnancy ended
shall be entitled to receive Medicaid through the postpartum period in
accordance with subrule 75.1(24).
j. If an infant loses eligibility under this
coverage group at the time of the first birthday due to an inability to meet
the income limit for children or if a child loses eligibility at the time of
the nineteenth birthday, but the infant or child is receiving inpatient
services in a medical institution , Medicaid shall continue under this coverage
group for the duration of the time continuous inpatient services are
provided.
(29)
Persons who are entitled to hospital insurance benefits under Part A of
Medicare (Qualified Medicare Beneficiary program). Medicaid shall be
available to persons who are entitled to hospital insurance under Part A of
Medicare to cover the cost of the Medicare Part A and B premiums, coinsurance
and deductibles, providing the following conditions are met:
a. The person's monthly income does not
exceed 100 percent of the federal poverty level (as defined by the United
States Office of Management and Budget and revised annually in accordance with
Section 673(2) of the Omnibus Budget Reconciliation Act of 1981) applicable to
a family of the size involved.
(1) The amount
of income shall be determined as under the federal Supplemental Security Income
(SSI) program.
(2) Income shall not
include any amount of social security income attributable to the cost-of-living
increase through the month following the month in which the annual revision of
the official poverty line is published.
b. The person's resources do not exceed the
maximum amount of resources that a person may have to obtain the full
low-income subsidy for Medicare Part D drug benefits. The amount of resources
shall be determined as under the SSI program unless the person lives and is
expected to live at least 30 consecutive days in a medical institution and has
a spouse at home. Then the resource determination shall be made according to
subrules 75.5(3) and 75.5(4).
c.
The effective date of eligibility is the first of the month after the month of
decision.
(30)
Presumptive eligibility for pregnant women. A pregnant woman
who is determined by a qualified provider to be presumptively eligible for
Medicaid, based only on her statements regarding family income, shall be
eligible for ambulatory prenatal care. Eligibility shall continue until the
last day of the month following the month of the presumptive eligibility
determination unless the pregnant woman is determined to be ineligible for
Medicaid during this period based on a Medicaid application filed either before
the presumptive eligibility determination or during this period. In this case,
presumptive eligibility shall end on the date Medicaid ineligibility is
determined. A pregnant woman who files a Medicaid application but withdraws
that application before eligibility is determined has not been determined
ineligible for Medicaid. The pregnant woman shall complete Form 470-2927 or
470-2927(S), Health Services Application, in order for the qualified provider
to make the presumptive eligibility determination. The qualified provider shall
complete Form 470-2629, Presumptive Medicaid Income Calculation, in order to
establish that the pregnant woman's family income is within the prescribed
limits of the Medicaid program.
If the pregnant woman files a Medicaid application in
accordance with rule 441-76.1 (249A) by the last day
of the month following the month of the presumptive eligibility determination,
Medicaid shall continue until a decision of ineligibility is made on the
application. Payment of claims for ambulatory prenatal care services provided
to a pregnant woman under this subrule is not
a. A qualified provider is defined as a
provider who is eligible for payment under the Medicaid program and who meets
all of the following criteria:
(1) Provides
one or more of the following services:
1.
Outpatient hospital services.
2.
Rural health clinic services (if contained in the state plan).
3. Clinic services furnished by or under the
direction of a physician, without regard to whether the clinic itself is
administered by a physician.
(2) Has been specifically designated by the
department in writing as a qualified provider for the purposes of determining
presumptive eligibility on the basis of the department 's determination that the
provider is capable of making a presumptive eligibility determination based on
family income.
(3) Meets one of the
following:
1. Receives funds under the Migrant
Health Centers or Community Health Centers (subsection 329 or subsection 330 of
the Public Health Service Act) or the Maternal and Child Health Services Block
Grant Programs (Title V of the Social Security Act) or the Health Services for
Urban Indians Program (Title V of the Indian Health Care Improvement
Act).
2. Participates in the
program established under the Special Supplemental Food Program for Women,
Infants, and Children (subsection 17 of the Child Nutrition Act of 1966) or the
Commodity Supplemental Food Program (subsection 4(a) of the Agriculture and
Consumer Protection Act of 1973).
3. Participates in a state perinatal
program.
4. Is an Indian health
service office or a health program or facility operated by a tribe or tribal
organization under the Indian Self-Determination Act.
b. The provider shall complete
Form 470-2579, Application for Authorization to Make Presumptive Medicaid
Eligibility Determinations, and submit it to the department for approval in
order to become certified as a provider qualified to make presumptive
eligibility determinations. Once the provider has been approved as a provider
qualified to make presumptive Medicaid eligibility determinations, Form
470-2582, Memorandum of Understanding Between the Iowa Department of Human
Services and a Qualified Provider, shall be signed by the provider and the
department .
c. Once the qualified
provider has made a presumptive eligibility determination for a pregnant woman,
the provider shall:
(1) Contact the
department to obtain a state identification number for the pregnant woman who
has been determined presumptively eligible.
(2) Notify the department in writing of the
determination within five working days after the date the presumptive
determination is made. A copy of the Presumptive Medicaid Eligibility Notice of
Decision, Form 470-2580 or 470-2580(S), shall be used for this
purpose.
(3) Inform the pregnant
woman in writing, at the time the determination is made, that if she chose not
to apply for Medicaid on the Health Services Application, Form 470-2927 or
470-2927(S), she has until the last day of the month following the month of the
preliminary determination to file an application with the department . A
Presumptive Medicaid Eligibility Notice of Decision, Form 470-2580, shall be
issued by the qualified provider for this purpose.
(4) Forward copies of the Health Services
Application, Form 470-2927 or 470-2927(S), to the appropriate offices for
eligibility determinations if the pregnant woman indicated on the application
that she was applying for any of the other programs listed on the application.
These copies shall be forwarded within two working days from the date of the
presumptive determination.
d. In the event that a pregnant woman needing
prenatal care does not appear to be presumptively eligible, the qualified
provider shall inform the pregnant woman that she may file an application at
the local department office if she wishes to have a formal determination
made.
e. Presumptive eligibility
shall end under any of the following conditions:
(1) The woman fails to file an application
for Medicaid in accordance with rule
441-76.1 (249A) by the last day
of the month following the month of the presumptive eligibility
determination.
(2) The woman files
a Medicaid application by the last day of the month following the month of the
presumptive eligibility determination and has been found ineligible for
Medicaid.
(3) Rescinded IAB 5/1/91,
effective 7/1/91.
f.
The adequate and timely notice requirements and appeal rights associated with
an application that is filed pursuant to rule
441-76.1 (249A) shall apply to
an eligibility determination made on the Medicaid application. However, notice
requirements and appeal rights of the Medicaid program shall not apply to a
woman who is:
(1) Issued a presumptive
eligibility decision by a qualified provider.
(2) Determined to be presumptively eligible
by a qualified provider and whose presumptive eligibility ends because the
woman fails to file an application by the last day of the month following the
month of the initial presumptive eligibility determination.
(3) Rescinded IAB 5/1/91, effective
7/1/91.
g. A woman shall
not be determined to be presumptively eligible for Medicaid more than once per
pregnancy.
(31)
Persons and families canceled from the family medical assistance
program (FMAP) due to the increased earnings of the specified relative in the
eligible group. Medicaid shall be available for a period of up to 12
additional months to families who are canceled from FMAP as provided in subrule
75.1 (14) because the specified relative of a dependent child receives
increased income from employment.
For the purposes of this subrule, "family" shall mean individuals living in the household whose needs and income were included in determining the FMAP eligibility of the household members at the time that the FMAP benefits were terminated. "Family" also includes those individuals whose needs and income would be taken into account in determining the FMAP eligibility of household members if the household were applying in the current month.
a. Increased income from
employment includes:
(1) Beginning
employment.
(2) Increased rate of
pay.
(3) Increased hours of
employment.
b. In order
to receive transitional Medicaid coverage under these provisions, an FMAP
family must have received FMAP during at least three of the six months
immediately preceding the month in which ineligibility occurred.
c. The 12 months' Medicaid transitional
coverage begins the day following termination of FMAP eligibility.
d. When ineligibility is determined to occur
retroactively, the transitional Medicaid coverage begins with the first month
in which FMAP eligibility was erroneously granted, unless the provisions of
paragraph"f" below apply.
e. Rescinded IAB 8/12/98, effective 10/1/98.
f. Transitional Medicaid shall not
be allowed under these provisions when it has been determined that the member
received FMAP in any of the six months immediately preceding the month of
cancellation as the result of fraud. Fraud shall be defined in accordance with
Iowa Code Supplement section 239B. 14.
g. During the transitional Medicaid period,
assistance shall be terminated at the end of the first month in which the
eligible group ceases to include a child, as defined by the family medical
assistance program.
h. If the
family receives transitional Medicaid coverage during the entire initial
six-month period and the department has received, by the twenty-first day of
the fourth month, a complete Notice of Decision/Quarterly Income Report, Form
470-2663 or 470-2663(S), Medicaid shall continue for an additional six months,
subject to paragraphs"g" and"i" of this
subrule.
(1) If the department does not
receive a completed form by the twenty-first day of the fourth month,
assistance shall be canceled.
(2) A
completed form is one that has all items answered, is signed, is dated, and is
accompanied by verification as required in paragraphs
75.57(1)"f" and 75.57(2)"/. "
i. Medicaid shall end at the close of the
first or fourth month of the additional six-month period if any of the
following conditions exists:
(1) The
department does not receive a complete Notice of Decision/Quarterly Income
Report, Form 470-2663 or 470-2663 (S), by the twenty-first day of the first
month or the fourth month of the additional six-month period as required in
paragraph 75.1(31)"/?," unless the family establishes good cause for failure to
report on a timely basis. Good cause shall be established when the family
demonstrates that one or more of the following conditions exist:
1. There was a serious illness or death of
someone in the family.
2. There was
a family emergency or household disaster, such as a fire, flood, or
tornado.
3. The family offers a
good cause beyond the family's control.
4. There was a failure to receive the
department 's notification for a reason not attributable to the family. Lack of
a forwarding address is attributable to the family.
(2) The specified relative had no earnings in
one or more of the previous three months, unless the lack of earnings was due
to an involuntary loss of employment, illness, or there were instances when
problems could negatively impact the client 's achievement of self-sufficiency
as described at 441-subrule 93.133(4).
(3) It is determined that the family's
average gross earned income, minus child care expenses for the children in the
eligible group necessary for the employment of the specified relative, during
the immediately preceding three-month period exceeds 185 percent of the federal
poverty level as defined by the United States Office of Management and Budget
and revised annually in accordance with Section 673(2) of the Omnibus Budget
Reconciliation Act of 1981.
j. These provisions apply to specified
relatives defined at paragraph 75.55(1)"a, " including:
(1) Any parent who is in the home. This
includes parents who are included in the eligible group as well as those who
are not.
(2) A stepparent who is
included in the eligible group and who has assumed the role of the caretaker
relative due to the absence or incapacity of the parent .
(3) A needy specified relative who is
included in the eligible group.
k. The timely notice requirements as provided
in 441-subrule 76.4(1) shall not apply when it is determined that the family
failed to meet the eligibility criteria specified in paragraph"g
" or"i" above. Transitional Medicaid shall be
terminated beginning with the first month following the month in which the
family no longer met the eligibility criteria. An adequate notice shall be
provided to the family when any adverse action is taken.
(32)
Persons and families terminated
from refugee cash assistance (RCA) because of income earned from
employment. Refugee medical assistance (RMA) shall be available as
long as the eight-month limit for the refugee program is not exceeded to
persons who are receiving RMA and who are canceled from the RCA program solely
because a member of the eligible group receives income from employment.
a. An RCA recipient shall not be required to
meet any minimum program participation time frames in order to receive RMA
coverage under these provisions.
b.
A person who returns to the home after the family became ineligible for RCA may
be included in the eligible group for RMA coverage if the person was included
on the assistance grant the month the family became ineligible for
RCA.
(33)
Qualified disabled and working persons. Medicaid shall be
available to cover the cost of the premium for Part A of Medicare (hospital
insurance benefits) for qualified disabled and working persons.
a. Qualified disabled and working persons are
persons who meet the following requirements:
(1) The person's monthly income does not
exceed 200 percent of the federal poverty level applicable to the family size
involved.
(2) The person's
resources do not exceed twice the maximum amount allowed under the supplemental
security income (SSI) program.
(3)
The person is not eligible for any other Medicaid benefits.
(4) The person is entitled to enroll in
Medicare Part A of Title XVIII under Section 1818 A of the Social Security Act
(as added by Section 6012 of OBRA 1989).
b. The amount of the person's income and
resources shall be determined as under the SSI program.
(34)
Specified low-income Medicare
beneficiaries. Medicaid shall be available to persons who are entitled
to hospital insurance under Part A of Medicare to cover the cost of the
Medicare Part B premium, provided the following conditions are met:
a. The person's monthly income exceeds 100
percent of the federal poverty level but is less than 120 percent of the
federal poverty level (as defined by the United States Office of Management and
Budget and revised annually in accordance with Section 673(2) of the Omnibus
Budget Reconciliation Act of 1981) applicable to a family of the size
involved.
b. The person's resources
do not exceed the maximum amount of resources that a person may have to obtain
the full low-income subsidy for Medicare Part D drug benefits.
c. The amount of income and resources shall
be determined as under the SSI program unless the person lives and is expected
to live at least 3 0 consecutive days in a medical institution and has a spouse
at home. Then the resource determination shall be made according to subrules
75.5(3) and 75.5(4). Income shall not include any amount of social security
income attributable to the cost-of-living increase through the month following
the month in which the annual revision of the official poverty level is
published.
d. The effective date of
eligibility shall be as set forth in rule
441-76.5 (249A).
(35)
Medically needy
persons.
a.
Coverage
groups. Subject to other requirements of this chapter, Medicaid shall
be available to the following persons:
(1)
Pregnant women. Pregnant women who would be eligible for FMAP-related coverage
groups except for excess income or resources. For FMAP-related programs,
pregnant women shall have the unborn child or children counted in the household
size as if the child or children were born and living with them.
(2) FMAP-related persons under the age of 19.
Persons under the age of 19 who would be eligible for an FMAP-related coverage
group except for excess income.
(3)
CMAP-related persons under the age of 21. Persons under the age of 21 who would
be eligible in accordance with subrule 75.1(15) except for excess
income.
(4) SSI-related persons.
Persons who would be eligible for SSI except for excess income or
resources.
(5) FMAP-specified
relatives. Persons whose income or resources exceed the family medical
assistance program's limit and who are a specified relative as defined at
subrule 75.55(1) living with a child who is determined dependent .
b.
Resources and income
of all persons considered.
(1)
Resources of all specified relatives and of all potentially eligible
individuals living together, except as specified at subparagraph
75.1(35)"b "(2) or who are excluded in accordance with the
provisions of rule 441-75.59 (249A), shall be
considered in determining eligibility of adults. Resources of all specified
relatives and of all potentially eligible individuals living together shall be
disregarded in determining eligibility of children. Income of all specified
relatives and of all potentially eligible individuals living together, except
as specified at subparagraph 75.1(35)"b "(2) or who are
excluded in accordance with the provisions of rule
441-75.59 (249 A), shall be
considered in determining eligibility.
(2) The amount of income of the responsible
relative that has been counted as available to an FMAP household or SSI
individual shall not be considered in determining the countable income for the
medically needy eligible group.
(3)
The resource determination shall be according to subrules 75.5(3) and 75.5(4)
when one spouse is expected to reside at least 30 consecutive days in a medical
institution .
c.
Resources.
(1) The resource limit
for adults in SSI-related households shall be $10,000 per household.
(2) Disposal of resources for less than fair
market value by SSI-related applicants or members shall be treated according to
policies specified in rule
441-75.23 (249A).
(3) The resource limit for FMAP- or
CMAP-related adults shall be $10,000 per household. In establishing eligibility
for children for this coverage group , resources of all persons in the eligible
group, regardless of age, shall be disregarded. In establishing eligibility for
adults for this coverage group , resources shall be considered according to
department of public health 641-subrule 75.4(2).
(4) The resources of SSI-related persons
shall be treated according to SSI policies.
(5) When a resource is jointly owned by
SSI-related persons and FMAP-related persons, the resource shall be treated
according to SSI policies for the SSI-related person and according to FMAP
policies for the FMAP-related persons.
d.
Income. All unearned and
earned income, unless specifically exempted, disregarded, deducted for work
expenses, or diverted shall be considered in determining initial and continuing
eligibility.
(1) Income policies specified in
subrules 75.57(1) through 75.57(8) and paragraphs 75.57(9)"b, " "c, "
"g, " "h, " and"i" regarding treatment of earned and
unearned income are applied to FMAP-related and CMAP-related persons when
determining initial eligibility and for determining continuing eligibility
unless otherwise specified. The three-step process for determining initial
eligibility and the two-step process for determining ongoing eligibility , as
described at rule 441-75.57 (249A), shall not
apply to medically needy persons.
(2) Income policies as specified in federal
SSI regulations regarding treatment of earned and unearned income are applied
to SSI-related persons when determining initial and continuing
eligibility.
(3) The monthly income
shall be determined prospectively unless actual income is available.
(4) The income for the certification period
shall be determined by adding both months' net income together to arrive at a
total.
(5) The income for the
retroactive certification period shall be determined by adding each month of
the retroactive period to arrive at a total.
e.
Medically needy income level
(MNIL) .
(1) The MNIL is based on 133
1/3 percent of the schedule of basic needs, as provided in subrule 75.58(2),
with households of one treated as households of two, as follows:
|
Number of Persons |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
|
MNIL |
$483 |
$483 |
$566 |
$666 |
$733 |
$816 |
$891 |
$975 |
$1058 |
$1158 |
Each additional person $116
(2) When determining household size for the
MNIL, all potential eligibles and all individuals whose income is considered as
specified in paragraph 75.1(35)"b " shall be included unless
the person has been excluded according to the provisions of rule
441-75.59(249A).
(3) The MNIL for
the certification period shall be determined by adding both months' MNIL to
arrive at a total. The MNIL for the retroactive certification period , when
applicable, shall be determined by adding each month of the retroactive period
to arrive at a total.
(4) The total
net countable income for the certification period shall be compared to the
total MNIL for the certification period based on family size as specified in
subparagraph (2).
If the total countable net income is equal to or less than the total MNIL, the medically needy individuals shall be eligible for Medicaid.
If the total countable net income exceeds the total MNIL, the
medically needy individuals shall not be eligible for Medicaid unless
(5) Effective date of
approval. Eligibility during the certification period or the retroactive
certification period when applicable shall be effective as of the first day of
the first month of the certification period or the retroactive certification
period when the medically needy income level (MNIL) is met.
f.
Verification of medical
expenses to be used in spenddown calculation. The applicant or member
shall submit evidence of medical expenses that are for noncovered Medicaid
services and for covered services incurred prior to the certification period to
the department on a claim form, which shall be completed by the medical
provider. In cases where the provider is uncooperative or where returning to
the provider would constitute an unreasonable requirement on the applicant or
member , the form shall be completed by the worker. Verification of medical
expenses for the applicant or member that are covered Medicaid services and
occurred during the certification period shall be submitted by the provider to
the Iowa Medicaid enterprise on a claim form. The applicant or member shall
inform the provider of the applicant 's or member 's spenddown obligation at the
time services are rendered or at the time the applicant or member receives
notification of a spenddown obligation. Verification of allowable expenses
incurred for transportation to receive medical care as specified in rule
441-78.13(249A) shall be verified on Form 470-0394, Medical Transportation
Claim.
Applicants who have not established that they met
g.
Spenddown calculation.
(1) Medical expenses that are incurred during
the certification period may be used to meet spenddown . Medical expenses
incurred prior to a certification period shall be used to meet spenddown if not
already used to meet spenddown in a previous certification period and if all of
the following requirements are met. The expenses:
1. Remain unpaid as of the first day of the
certification period .
2. Are not
Medicaid-payable in a previous certification period or the retroactive
certification period .
3. Are not
incurred during any prior certification period with the exception of the
retroactive period in which the person was conditionally eligible but did not
meet spenddown .
Notwithstanding numbered paragraphs "1" through "3," paid
medical expenses from the
(2) Order of deduction. Spenddown shall be
adjusted when a bill for a Medicaid-covered service incurred during the
certification period has been applied to meet spenddown if a bill for a covered
service incurred prior to the certification period is subsequently received.
Spenddown shall also be adjusted when a bill for a noncovered Medicaid service
is subsequently received with a service date prior to the Medicaid-covered
service. Spenddown shall be adjusted when an unpaid bill for a Medicaid-covered
service incurred during the certification period has been applied to meet
spenddown if a paid bill for a covered service incurred in the certification
period is subsequently received with a service date prior to the date of the
notice of spenddown status.
If
1. Medicare and other
health insurance premiums, deductibles, or coinsurance charges. Exception: When
some of the household members are eligible for full Medicaid benefits under the
Health Insurance Premium Payment Program (HIPP), as provided in rule
441-75.21(249A), the health insurance premium shall not be allowed as a
deduction to meet the spenddown obligation of those persons in the household in
the medically needy coverage group .
2. An average statewide monthly standard
deduction for the cost of medically necessary personal care services provided
in a licensed residential care facility shall be allowed as a deduction for
spenddown . These personal care services include assistance with activities of
daily living such as preparation of a special diet, personal hygiene and
bathing, dressing, ambulation, toilet use, transferring, eating, and managing
medication.
The average statewide monthly standard deduction for personal care services shall be based on the average per day rate of health care costs associated with residential care facilities participating in the state supplementary assistance program for a 30.4-day month as computed by multiplying the previous year's average per day rate by the inflation factor increase during the preceding calendar year ending December 31 of the Consumer Price Index for All Urban Consumers as published by the Bureau of Labor Statistics.
3. Medical
expenses for necessary medical and remedial services that are recognized under
state law but not covered by Medicaid, chronologically by date of
submission.
4. Medical expenses for
acupuncture, chronologically by date of submission.
5. Medical expenses for necessary medical and
remedial services that are covered by Medicaid, chronologically by date of
submission.
(3) When
incurred medical expenses have reduced income to the applicable MNIL, the
individuals shall be eligible for Medicaid.
(4) Medical expenses reimbursed by a public
program other than Medicaid prior to the certification period shall not be
considered a medical deduction.
h.
Medicaid services.
Persons eligible for Medicaid as medically needy will be eligible for all
services covered by Medicaid except:
(1) Care
in a nursing facility or an intermediate care facility for the mentally
retarded.
(2) Care in an
institution for mental disease.
(3)
Care in a Medicare-certified skilled nursing facility.
i.
Reviews. Reviews of
eligibility shall be made for SSI-related , CMAP-related, and FMAP-related
medically needy members with a zero spenddown as often as circumstances
indicate but in no instance shall the period of time between reviews exceed 12
months.
j.
Redetermination. When an SSI-related , CMAP-related, or FMAP-related
member who has had ongoing eligibility because of a zero spenddown has income
that exceeds the MNIL, a redetermination of eligibility shall be completed to
change the member 's eligibility to a two-month certification with spenddown .
This redetermination shall be effective the month the income exceeds the MNIL
or the first month following timely notice.
(1) The Health Services Application, Form
470-2927 or 470-2927(S), or the Health and Financial Support Application, Form
470-0462 or Form 470-0466 (Spanish), shall be used to determine eligibility for
SSI-related medically needy when an SSI recipient has been determined to be
ineligible for SSI due to excess income or resources in one or more of the
months after the effective date of the SSI eligibility decision.
(2) All eligibility factors shall be reviewed
on redeterminations of eligibility.
k.
Recertifications. A new
application shall be made when the certification period has expired and there
has been a break in assistance as defined at rule
441-75.25 (249A). When the
certification period has expired and there has not been a break in assistance ,
the person shall use the Medicaid Review, Form 470-3118 or 470-3118(S), to be
recertified.
l.
Disability
determinations. An applicant receiving social security disability
benefits under Title II of the Social Security Act or railroad retirement
benefits based on the Social Security Act definition of disability by the
Railroad Retirement Board shall be deemed disabled without any further
determination. In other cases under the medically needy program, the department
shall conduct an independent determination of disability unless the applicant
has been denied supplemental security income benefits based on lack of
disability and does not allege either (1) a disabling condition different from
or in addition to that considered by the Social Security Administration, or (2)
that the applicant 's condition has changed or deteriorated since the most
recent Social Security Administration determination.
(1) In conducting an independent
determination of disability, the department shall use the same criteria
required by federal law to be used by the Social Security Administration of the
United States Department of Health and Human Services in determining disability
for purposes of Supplemental Security Income under Title XVI of the Social
Security Act. The disability determination services bureau of the division of
vocational rehabilitation shall make the initial disability determination on
behalf of the department .
(2) For
an independent determination of disability, the applicant or the applicant 's
authorized representative shall complete, sign and submit Form 470-4459 or
470-4459(S), Authorization to Disclose Information to the Department of Human
Services, and either:
1. Form 470-2465,
Disability Report for Adults, if the applicant is aged 18 or over; or
2. Form 470-3912, Disability Report for
Children, if the applicant is under the age of 18.
(3) In connection with any independent
determination of disability, the department shall determine whether
reexamination of the person's medical condition will be necessary for periodic
redeterminations of eligibility. When reexamination is required, the member or
the member 's authorized representative shall complete and submit the same forms
as required in subparagraph (2).
(36)
Expanded specified low-income
Medicare beneficiaries. As long as 100 percent federal funding is
available under the federal Qualified Individuals (QI) Program, Medicaid
benefits to cover the cost of the Medicare Part B premium shall be available to
persons who are entitled to Medicare Part A provided the following conditions
are met:
a. The person is not otherwise
eligible for Medicaid.
b. The
person's monthly income is at least 120 percent of the federal poverty level
but is less than 135 percent of the federal poverty level (as defined by the
United States Office of Management and Budget and revised annually in
accordance with Section 673(2) of the Omnibus Budget Reconciliation Act of
1981) applicable to a family of the size involved.
c. The person's resources do not exceed the
maximum amount of resources that a person may have to obtain the full
low-income subsidy for Medicare Part D drug benefits.
d. The amount of the income and resources
shall be determined the same as under the SSI program unless the person lives
and is expected to live at least 30 consecutive days in a medical institution
and has a spouse at home. Then the resource determination shall be made
according to subrules 75.5(3) and 75.5(4). Income shall not include any amount
of social security income attributable to the cost-of-living increase through
the month following the month in which the annual revision of the official
poverty level is published.
e. The
effective date of eligibility shall be as set forth in rule
441-76.5(249A).
(37)
Home health specified low-income Medicare beneficiaries.
Rescinded IAB 10/30/02, effective 1/1/03.
(38)
Continued Medicaidfor disabled
children from August 22, 1996. Medical assistance shall be available
to persons who were receiving SSI as of August 22, 1996, and who would continue
to be eligible for SSI but for Section 211(a) of the Personal Responsibility
and Work Opportunity Act of 1996 (
P.L.
104-193 ).
(39)
Working persons with
disabilities.
a. Medical assistance
shall be available to all persons who meet all of the following conditions:
(1) They are disabled as determined pursuant
to rule 441-75.20 (249A), except that
being engaged in substantial gainful activity will not preclude a determination
of disability.
(2) They are less
than 65 years of age.
(3) They are
members of families (including families of one) whose income is less than 250
percent of the most recently revised official federal poverty level for the
family. Family income shall include gross income of all family members, less
supplemental security income program disregards, exemptions, and exclusions,
including the earned income disregards. However, income attributable to a
social security cost-of-living adjustment shall be included only in determining
eligibility based on a subsequently published federal poverty level.
(4) They receive earned income from
employment or self-employment or are eligible under paragraph
75.1(39)"c. "
(5)
They would be eligible for medical assistance under another coverage group set
out in this rule (other than the medically needy coverage groups at subrule
75.1(35)), disregarding all income, up to $10,000 of available resources, and
any additional resources held by the disabled individual in a retirement
account, a medical savings account, or an assistive technology account. For
this purpose, disability shall be determined as under subparagraph
75.1(39)"a"(l) above.
(6) They have
paid any premium assessed under paragraph 75.1(39)"b "
below.
b. Eligibility
for a person whose gross income is greater than 150 percent of the federal
poverty level for an individual is conditional upon payment of a premium. Gross
income includes all earned and unearned income of the conditionally eligible
person, except that income attributable to a social security cost-of-living
adjustment shall be included only in determining premium liability based on a
subsequently published federal poverty level. A monthly premium shall be
assessed at the time of application and at the annual review. The premium
amounts and the federal poverty level increments above 150 percent of the
federal poverty level used to assess premiums will be adjusted annually on
August 1.
(1) Beginning with the month of
application, the monthly premium amount shall be established based on projected
average monthly income. The monthly premium established shall not be increased
for any reason before the next eligibility review. The premium shall not be
reduced due to a change in the federal poverty level but may be reduced or
eliminated prospectively before the next eligibility review if a reduction in
projected average monthly income is verified.
(2) Eligible persons are required to complete
and return Form 470-3118 or 470-3118(S), Medicaid Review, with income
information during the twelfth month of the annual enrollment period to
determine the premium to be assessed for the next 12-month enrollment
period.
(3) Premiums shall be
assessed as follows:
|
IF THE INCOME OF THE |
THE MONTHLY PREMIUM IS: |
|
150% of Federal Poverty Level |
$35 |
|
165% of Federal Poverty Level |
$48 |
|
180% of Federal Poverty Level |
$57 |
|
200% of Federal Poverty Level |
$67 |
|
225% of Federal Poverty Level |
$79 |
|
250% of Federal Poverty Level |
$92 |
|
300% of Federal Poverty Level |
$115 |
|
350% of Federal Poverty Level |
$140 |
|
400% of Federal Poverty Level |
$165 |
|
450% of Federal Poverty Level |
$190 |
|
550% of Federal Poverty Level |
$237 |
|
650% of Federal Poverty Level |
$286 |
|
750% of Federal Poverty Level |
$337 |
|
850% of Federal Poverty Level |
$398 |
|
1000% of Federal Poverty Level |
$477 |
|
1150% of Federal Poverty Level |
$559 |
|
1300% of Federal Poverty Level |
$644 |
|
1480% of Federal Poverty Level |
$744 |
|
1550% of Federal Poverty Level |
$829 |
(4)
Eligibility is contingent upon the payment of any assessed premiums. Medical
assistance eligibility shall not be made effective for a month until the
premium assessed for the month is paid. The premium must be paid within three
months of the month of coverage or of the month of initial billing, whichever
is later, for the person to be eligible for the month.
(5) When the department notifies the
applicant of the amount of the premiums, the applicant shall pay any premiums
due as follows:
1. The premium for each month
is due the fourteenth day of the month the premium is to cover. EXCEPTIONS: The
premium for the month of initial billing is due the fourteenth day of the
following month; premiums for any months prior to the month of initial billing
are due on the fourteenth day of the third month following the month of
billing.
2. If the fourteenth day
falls on a weekend or a state holiday, payment is due the first working day
following the holiday or weekend.
3. When any premium payment due in the month
it is to cover is not received by the due date, Medicaid eligibility shall be
canceled.
(6) Payments
received shall be applied in the following order:
1. To the month in which the payment is
received if the premium for the current calendar month is unpaid.
2. To the following month when the payment is
received after a billing statement has been issued for the following
month.
3. To prior months when a
full payment has not been received. Payments shall be applied beginning with
the most recent unpaid month before the current calendar month, then the oldest
unpaid prior month and forward until all prior months have been paid.
4. When premiums for all months above have
been paid, any excess shall be held and applied to any months for which
eligibility is subsequently established, as specified in numbered paragraphs
"1," "2," and "3" above, and then to future months when a premium becomes
due.
5. Any excess on an inactive
account shall be refunded to the client after two calendar months of inactivity
or of a zero premium or upon request from the client .
(7) An individual's case may be reopened when
Medicaid eligibility is canceled for nonpayment of premium. However, the full
premium must be received by the department on or before the last day of the
month following the month the premium is to cover.
(8) Premiums may be submitted in the form of
money orders or personal checks to the address printed on the coupon attached
to Form 470-3902, MEPD Billing Statement.
(9) Once an individual is canceled from
Medicaid due to nonpayment of premiums, the individual must reapply to
establish Medicaid eligibility unless the reopening provisions of this subrule
apply.
(10) When a premium due in
the month it is to cover is not received by the due date, a notice of decision
will be issued to cancel Medicaid. The notice will include reopening provisions
that apply if payment is received and appeal rights.
(11) Form 470-3902, MEPD Billing Statement,
shall be used for billing and collection.
c. Members in this coverage group who become
unable to work due to a change in their medical condition or who lose
employment shall remain eligible for a period of six months from the month of
the change in their medical condition or loss of employment as long as they
intend to return to work and continue to meet all other eligibility criteria
under this subrule. Members shall submit Form 470-4856, MEPD Intent to Return
to Work, to report on the end of their employment and their intent to return to
employment.
d. For purposes of this
subrule, the following definitions apply:
"Assistive technology" is the systematic application of technologies, engineering, methodologies, or scientific principles to meet the needs of and address the barriers confronted by individuals with disabilities in areas that include education, rehabilitation, technology devices and assistive technology services.
"Assistive technology accounts" include funds in contracts, savings, trust or other financial accounts, financial instruments or other arrangements with a definite cash value set aside and designated for the purchase, lease or acquisition of assistive technology, assistive technology devices or assistive technology services. Assistive technology accounts must be held separate from other accounts and funds and must be used to purchase, lease or otherwise acquire assistive technology, assistive technology services or assistive technology devices for the working person with a disability when a physician, certified vocational rehabilitation counselor, licensed physical therapist, licensed speech therapist, or licensed occupational therapist has established the medical necessity of the device, technology, or service and determined the technology, device, or service can reasonably be expected to enhance the individual's employment.
"Assistive technology device " is any item, piece of equipment, product system or component part, whether acquired commercially, modified or customized, that is used to increase, maintain, or improve functional capabilities or address or eliminate architectural, communication, or other barriers confronted by persons with disabilities.
"Assistive technology service " means any service that directly assists an individual with a disability in the selection, acquisition, or use of an assistive technology device or other assistive technology. It includes, but is not limited to, services referred to or described in the Assistive Technology Act of 1998, 29 U.S.C. 3002(4).
"Family " if the individual is under 18 and unmarried, includes parents living with the individual, siblings under 18 and unmarried living with the individual, and children of the individual who live with the individual. If the individual is 18 years of age or older, or married, "family" includes the individual's spouse living with the individual and any children living with the individual who are under 18 and unmarried. No other persons shall be considered members of an individual's family. An individual living alone or with others not listed above shall be considered to be a family of one.
"Medical savings account" means an account exempt from federal income taxation pursuant to Section 220 of the United States Internal Revenue Code ( 26 U.S.C. § 220) .
"Retirement account" means any retirement or pension fund or account, listed in Iowa Code section 627.6(8) "f" as exempt from execution, regardless of the amount of contribution, the interest generated, or the total amount in the fund or account.
(40)
People who have been screened and found to need treatment for breast or
cervical cancer.
a. Medical
assistance shall be available to people who:
(1) Have been screened for breast or cervical
cancer under the Centers for Disease Control and Prevention Breast and Cervical
Cancer Early Detection Program established under Title XV of the Public Health
Service Act and have been found to need treatment for either breast or cervical
cancer (including a precancerous condition);
(2) Do not otherwise have creditable
coverage, as that term is defined by the Health Insurance Portability and
Accountability Act (HIPAA) (
42 U.S.C. Section
300gg(c)(l)) , and are not
eligible for medical assistance under Iowa Code section
249A.3(1);
and
(3) Are under the age of
65.
b. Eligibility
established under paragraph"a" continues until the person is:
(1) No longer receiving treatment for breast
or cervical cancer;
(2) No longer
under the age of 65; or
(3) Covered
by creditable coverage or eligible for medical assistance under Iowa Code
section
249A.3(1).
c. Presumptive eligibility. A
person who has been screened for breast or cervical cancer under the Centers
for Disease Control and Prevention Breast and Cervical Cancer Early Detection
Program established under Title XV of the Public Health Service Act, who has
been found to need treatment for either breast or cervical cancer (including a
precancerous condition), and who is determined by a qualified provider to be
presumptively eligible for medical assistance under paragraph"a
" shall be eligible for medical assistance until the last day of the
month following the month of the presumptive eligibility determination if no
Medicaid application is filed in accordance with rule
441-76.1 (249A) by that day or
until the date of a decision on a Medicaid application filed in accordance with
rule 441-76.1 (249A) by the last day
of the month following the month of the presumptive eligibility determination,
whichever is earlier.
The person shall complete Form 470-2927 or 470-2927(S), Health Services Application, in order for the qualified provider to make the presumptive eligibility determination. Presumptive eligibility shall begin no earlier than the date the qualified Medicaid provider determines eligibility.
Payment of claims for services provided to a person under
this paragraph is not
(1) A provider who is
qualified to determine presumptive eligibility is defined as a provider who:
1. Is eligible for payment under the Medicaid
program; and
2. Either:
* Has been named lead agency for a county or regional local
breast and cervical cancer early detection program under a contract with the
* Has a cooperative agreement with the
3. Has made application and has been
specifically designated by the department in writing as a qualified provider
for the purpose of determining presumptive eligibility under this
rule.
(2) The provider
shall complete Form 470-3864, Application for Authorization to Make Presumptive
Medicaid Eligibility Determinations (BCCT), and submit it to the department for
approval in order to be designated as a provider qualified to make presumptive
eligibility determinations. Once the department has approved the provider's
application, the provider and the department shall sign Form 470-3865,
Memorandum of Understanding with a Qualified Provider for People with Breast or
Cervical Cancer Treatment. When both parties have signed the memorandum, the
department shall designate the provider as a qualified provider and notify the
provider.
(3) When a qualified
provider has made a presumptive eligibility determination for a person, the
provider shall:
1. Contact the department to
obtain a state identification number for the person who has been determined
presumptively eligible.
2. Notify
the department in writing of the determination within five working days after
the date the presumptive eligibility determination is made. The provider shall
use a copy of Form 470-2580 or 470-25 80(S), Presumptive Medicaid Eligibility
Notice of Decision, for this purpose.
3. Inform the person in writing, at the time
the determination is made, that if the person has not applied for Medicaid on
Form 470-2927 or 470-2927(S), Health Services Application, the person has until
the last day of the month following the month of the preliminary determination
to file the application with the department . The qualified provider shall use
Form 470-2580 or 470-2580(S), Presumptive Medicaid Eligibility Notice of
Decision, for this purpose.
4.
Forward copies of Form 470-2927 or 470-2927(S), Health Services Application, to
the appropriate department office for eligibility determination if the person
indicated on the application that the person was applying for any of the other
programs. The provider shall forward these copies and proof of screening for
breast or cervical cancer under the Centers for Disease Control and Prevention
Breast and Cervical Cancer Early Detection Program within two working days from
the date of the presumptive eligibility determination.
(4) In the event that a person needing care
does not appear to be presumptively eligible, the qualified provider shall
inform the person that the person may file an application at the county
department office if the person wishes to have an eligibility determination
made by the department .
(5)
Presumptive eligibility shall end under either of the following conditions:
1. The person fails to file an application
for Medicaid in accordance with rule
441-76.1 (249A) by the last day
of the month following the month of the presumptive eligibility
determination.
2. The person files
a Medicaid application by the last day of the month following the month of the
presumptive eligibility determination and is found ineligible for
Medicaid.
(6) Adequate
and timely notice requirements and appeal rights shall apply to an eligibility
determination made on a Medicaid application filed pursuant to rule
441-76.1(249A). However, notice requirements and appeal rights of the Medicaid
program shall not apply to a person who is:
1.
Denied presumptive eligibility by a qualified provider.
2. Determined to be presumptively eligible by
a qualified provider and whose presumptive eligibility ends because the person
fails to file an application by the last day of the month following the month
of the presumptive eligibility determination.
(7) A new period of presumptive eligibility
shall begin each time a person is screened for breast or cervical cancer under
the Centers for Disease Control and Prevention Breast and Cervical Cancer Early
Detection Program established under Title XV of the Public Health Service Act,
is found to need treatment for breast or cervical cancer, and files Form
470-2927 or 470-2927(S), Health Services Application, with a qualified
provider.
(41)
Persons eligible for family
planning services under demonstration waiver. Rescinded IAB 10/11/17,
effective 10/1/17.
(42)
Medicaid for independent young adults. Medical assistance
shall be available, as assistance related to the family medical assistance
program, to a person who left a foster care placement on or after May 1, 2006,
and meets all of the following conditions:
a.
The person is at least 18 years of age and under 21 years of age.
b. On the person's eighteenth birthday, the
person resided in foster care and Iowa was responsible for the foster care
payment pursuant to Iowa Code section
234.35.
c. The person is not a mandatory household
member or receiving Medicaid benefits under another coverage group .
d. The person has income below 200 percent of
the most recently revised federal poverty level for the person's household
size.
(1) "Household" shall mean the person
and any of the following people who are living with the person and are not
active on another Medicaid case:
1. The
person's own children;
2. The
person's spouse; and
3. Any
children of the person's spouse who are under the age of 18 and unmarried.
No one else shall be considered a
(2) The department shall determine
the household's countable income pursuant to rule
441-75.57 (249A). Twenty percent
of earned income shall be disregarded.
(3) A person found to be income-eligible upon
application or upon annual redetermination of eligibility shall remain
income-eligible for 12 months regardless of any change in income or household
size.
(43)
Medicaid for children with disabilities. Medical assistance
shall be available to children who meet all of the following conditions on or
after January 1, 2009:
a. The child is under
19 years of age.
b. The child is
disabled as determined pursuant to rule
441-75.20 (249A) based on the
disability standards for children used for Supplemental Security Income (SSI)
benefits under Title XVI of the Social Security Act, but without regard to any
income or asset eligibility requirements of the SSI program.
c. The child is enrolled in any group health
plan available through the employer of a parent living in the same household as
the child if the employer contributes at least 50 percent of the total cost of
annual premiums for that coverage. The parent shall enroll the child and pay
any employee premium required to maintain coverage for the child.
d. The child's household has income at or
below 300 percent of the federal poverty level applicable to a family of that
size.
(1) For this purpose, the child's
household shall include any of the following persons who are living with the
child and are not receiving Medicaid on another case:
1. The child's parents.
2. The child's siblings under the age of
19.
3. The child's
spouse.
4. The child's
children.
5. The children of the
child's spouse.
(2) Only
those persons identified in subparagraph (1) shall be considered a member of
the child's household. A person who receives medically needy coverage with a
spenddown or limited benefits such as Medicare savings programs only is not
considered to be "receiving Medicaid" for the purposes of subparagraph (1). A
child who lives alone or with persons not identified in subparagraph (1) shall
be considered as having a household of one.
(3) For this purpose, the income of all
persons included in the child's household shall be determined as provided for
SSI-related groups under subrule 75.13(2).
(4) The federal poverty levels used to
determine eligibility shall be revised annually on April 1.
(44)
Presumptive eligibility for children. Medical assistance shall
be available to children under the age of 19 who are determined by a qualified
entity to be presumptively eligible for medical assistance pursuant to this
subrule.
a.
Qualified
entity. A "qualified entity" is an entity described in paragraphs (1)
through (10) of the definition of the term at
42 CFR
435.1101, as amended to October 1, 2008,
that:
(1) Has been determined by the
department to be capable of making presumptive determinations of eligibility,
and
(2) Has signed an agreement
with the department as a qualified entity.
b.
Application process.
Families requesting assistance for children under this subrule shall apply with
a qualified entity using the form specified in 441-paragraph 76.1(1) "f
" The qualified entity shall use the department 's web-based system to
make the presumptive eligibility determination, based on the information
provided in the application.
(1) All
presumptive eligibility applications shall be forwarded to the department for a
full Medicaid or hawki eligibility determination, regardless of the child's
presumptive eligibility status.
(2)
The date a valid application was received by the qualified entity establishes
the date of application for purposes of determining the effective date of
Medicaid or hawki eligibility unless the qualified entity received the
application on a weekend or state holiday. Applications received by the
qualified entity on a weekend or a state holiday shall be considered to be
received on the first business day following the weekend or state holiday.
(3) The qualified entity shall
issue Form 470-2580 or 470-2580(S), Presumptive Medicaid Eligibility Notice of
Decision, to inform the applicant of the decision on the application as soon as
possible but no later than within two working days after the date the
determination is made.
(4) Timely
and adequate notice requirements and appeal rights of the Medicaid program
shall not apply to presumptive eligibility decisions made by a qualified
entity.
c.
Eligibility requirements. To be determined presumptively eligible for
medical assistance, a child shall meet the following eligibility requirements.
(1) Age. The child must be under the age of
19.
(2) Household income. Household
income must be less than 300 percent of the federal poverty level for a
household of the same size. For this purpose, the household shall include the
applicant child and any sibling (of whole or half blood, or adoptive), spouse,
parent , or stepparent living with the applicant child. This determination shall
be based on the household's gross income, with no deductions, diversions, or
disregards.
(3) Citizenship or
qualified alien status. The child must be a citizen of the United States or a
qualified alien as defined in subrule 75.11(2).
(4) Iowa residency. The child must be a
resident of Iowa.
(5) Prior
presumptive eligibility. A child shall not be determined presumptively eligible
more than once in a 12-month period. The first month of the 12-month period
begins with the month the application is received by the qualified
entity.
d.
Period of presumptive eligibility. Presumptive eligibility shall begin
with the date that presumptive eligibility is determined and shall continue
until the earliest of the following dates:
(1)
The last day of the next calendar month;
(2) The day the child is determined eligible
for Medicaid;
(3) The last day of
the month that the child is determined eligible for hawki; or
(4) The day the child is determined
ineligible for Medicaid and hawki. Withdrawal of the Medicaid or hawki
application before eligibility is determined shall not affect the child's
eligibility during the presumptive period.
e.
Services covered.
Children determined presumptively eligible under this subrule shall be entitled
to all Medicaid-covered services, including early and periodic screening,
diagnosis, and treatment (EPSDT) services. Payment of claims for Medicaid
services provided to a child during the presumptive eligibility period,
including EPSDT services, is not dependent upon a determination of Medicaid or
hawki eligibility by the department .
(45)
Medicaid for former foster care
youth Effective January 1, 2014, medical assistance shall be available
to a person who meets all of the following conditions:
a. The person is at least 18 years of age (or
such higher age to which foster care is provided to the person) and under 26
years of age;
b. The person is not
described in or enrolled under any of Subclauses (I) through (VII) of Section
1902(a)(10)(A)(i) of Title XIX of the Social Security Act or is described in
any of such subclauses but has income that exceeds the level of income
applicable under Iowa's state Medicaid plan for eligibility to enroll for
medical assistance under such subclause;
c. The person was in foster care under the
responsibility of Iowa on the date of attaining 18 years of age or such higher
age to which foster care is provided; and
d. The person was enrolled in the Iowa
Medicaid program under Title XIX of the Social Security Act while in such
foster care.
This rule is intended to implement Iowa Code sections 249A.3, 249A.4 and 249A.6.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.