reglab/statecodes huggingface dataset:
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 86 - Healthy and Well Kids in Iowa (HAWK-I) Program › Rule 441-86.2 - Eligibility Factors

Current through Register Vol. 47, No. 3, July 24, 2024
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).
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 86 - Healthy and Well Kids in Iowa (HAWK-I) Program › Rule 441-86.3 - Application Process

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Who may apply.
Each person wishing to do so shall have the
				opportunity to apply for the hawki program in accordance with rule
				441-76.1 (249A).
(2)
Applications.
An
				application for the hawki program shall be filed in accordance with rule
				441-76.1 (249 A).
(3)
Place of filing.
An
				application for the hawki program may be filed with the department through an
				Internet website, by telephone, through other electronic means, or through an
				exchange, disproportionate share hospital, federally qualified health center,
				or other facility in which outstationing activities are provided.
(4)
Date and method of
				filing.
The application is considered filed when received in
				accordance with rule 441- 76.1(249A).
(5)
Right to withdraw
				application.
After an application has been filed, the applicant may
				withdraw the application at any time prior to the eligibility determination.
				Requests for voluntary withdrawal of the application shall be documented, and
				the applicant shall be sent a notice of decision confirming the
				request.
(6)
Application
				not required.
a. An application
				shall not be required when a child becomes ineligible for Medicaid.
b. A new application shall not be required
				when an eligible child is added to an existing hawki eligible group.
c. A new application shall not be required
				when a child moves between supplemental dental-only coverage as specified in
				rule 441-86.20(5141) and full medical and dental coverage.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 86 - Healthy and Well Kids in Iowa (HAWK-I) Program › Rule 441-86.4 - Coordination With Medicaid

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
HAWK-I applicant eligible for Medicaid.
At the time of initial
				application, if it is determined the child is eligible for Medicaid in
				accordance with the provisions of rule
				441-75.1 (249 A),
				with the exception of meeting a spenddown under the medically needy program at
				441-subrule 75.1(35), the child shall be enrolled in the Medicaid
				program.
(2)
HA WK-I
				enrollee eligible for Medicaid.
At the time of the annual review, if
				the child is determined eligible for Medicaid in accordance with the provisions
				of rule
				441-75.1 (249A),
				with the exception of meeting a spenddown under the medically needy program at
				441-subrule 75.1(35), the child shall be enrolled in Medicaid effective the
				first day following the expiration of the 12-month HAWK-I enrollment
				period.
(3)
Medicaid member
				becomes ineligible.
If a child becomes ineligible for Medicaid under
				the provisions of rule
				441-75.1 (249A),
				with the exception of meeting a spenddown under the medically needy program at
				441-subrule 75.1(35), the child shall be enrolled in the HAWK-I program if
				otherwise eligible.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 86 - Healthy and Well Kids in Iowa (HAWK-I) Program › Rule 441-86.5 - Effective Date of Coverage

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Initial application.
Coverage for a child who is determined
				eligible for the HAWK-I program on the basis of an initial application for
				either HAWK-I or Medicaid shall be effective the first day of the month
				following the month in which the application is filed, regardless of the day of
				the month the application is filed. However, when the child does not meet the
				provisions of paragraph 86.2(4)
"a,"
coverage shall be
				effective the first day of the month following the month in which health
				insurance coverage is lost. Also, a one-month waiting period shall be imposed
				for a child who is subject to a monthly premium pursuant to paragraph
				86.8(2)
"c"
when the child's health insurance coverage ended in
				the month of application. EXCEPTIONS: A waiting period shall not be imposed if
				any of the following conditions apply:
a. The
				child is moving from Medicaid to HAWK-I.
b. The child has a medical condition that,
				without medical care, would cause serious disability, loss of function, or
				death.
c. The cost of health
				insurance coverage for the child exceeds 5 percent of the family's gross
				income. The cost of health insurance for the child shall be the difference
				between the premium for coverage with and without the child.
d. The health insurance was provided through
				an individual plan.
e. The child's
				health insurance coverage was lost due to:
(1)
				Domestic violence.
(2) Divorce or
				death of a parent.
(3) An
				involuntary loss of employment that qualified the parent for dependent
				coverage, including but not limited to layoff, business closure, reduction in
				hours, or termination.
(4) A job
				change to a new employer that does not offer the parent dependent coverage or
				that requires a waiting period before children can be enrolled in dependent
				coverage.
(5) Utilization of the
				maximum lifetime coverage amount.
(6) Expiration of coverage under
				COBRA.
(7) Discontinuation of
				dependent coverage by the parent's employer.
(8) A reason beyond the control of the
				parent, such as a serious illness of the parent, fire, flood, or natural
				disaster.
f. The
				child's parent is determined eligible for advance payment of the premium tax
				credit for enrollment in a qualified health plan through the Health Insurance
				Marketplace because the employer-sponsored insurance in which the family was
				enrolled is determined unaffordable in accordance with
				26 CFR
				1.36B-2(c)(3)(v).
g. The cost of family coverage that includes
				the child exceeds 9.5 percent of the annual household income.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 86 - Healthy and Well Kids in Iowa (HAWK-I) Program › Rule 441-86.6 - Selection of a Plan

Current through Register Vol. 47, No. 3, July 24, 2024
Upon the child's eligibility effective date, the child shall
				  be assigned to a health or dental plan using the department's passive
				  enrollment process. The enrollee may change plans only at the time of the
				  annual review unless the provisions of paragraph 86.6(1)
"a"
or subrule 86.6(2) apply.
(1)
Period of enrollment.
Once enrolled in a health or dental
				plan, the child shall remain enrolled in the health or dental plan for a period
				of 12 months.
a.
Exceptions.
A child may be enrolled in a plan for less than 12 months
				if:
(1) The child is disenrolled in
				accordance with the provisions of rule
				441-86.7 (5141). If a child is
				disenrolled from the health or dental plan and subsequently reapplies before
				the end of the original 12-month enrollment period, the child shall be enrolled
				in the health or dental plan from which the child was originally
				disenrolled.
(2) The child is added
				to an existing enrollment. When a family requests to add an eligible child, the
				child shall be enrolled for the months remaining in the current enrollment
				period.
(3) A request to change
				plans is accepted in accordance with paragraph 86.6(1)
"b."
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 86 - Healthy and Well Kids in Iowa (HAWK-I) Program › Rule 441-86.7 - Cancellation

Current through Register Vol. 47, No. 3, July 24, 2024
The child's eligibility for the hawki program shall be
				  canceled before the end of the 12-month enrollment period for any of the
				  following:
(1)
Child moves
				from the service area.
Rescinded lAB 1/13/10, effective
				3/1/10.
(2)
Age.
The child shall be canceled from the hawki program as of the first day of the
				month following the month in which the child attained the age of 19.
(3)
Nonpayment of premiums.
The child shall be canceled from the program as of the first day of the month
				in which premiums are not paid in accordance with the provisions of subrules
				86.8(3) and 86.8(5), unless premiums are subsequently received in accordance
				with the grace period provisions of subrule 86.8(4).
(4)
Iowa residence
				abandoned.
The child shall be canceled from the program as of the
				first day of the month following the month in which the child relocated to
				another state. Eligibility shall not be canceled when the child is temporarily
				absent from the state in accordance with the provisions of 441-subrule
				75.10(2).
(5)
Eligible for
				Medicaid.
The child shall be canceled from the program as of the first
				day of the month following the month in which Medicaid eligibility is obtained.
				If there are months during which the child is covered by both the Medicaid and
				hawki programs, the hawki program shall be the primary payor and Medicaid shall
				be the payor of last resort.
(6)
Enrolled in other health insurance coverage.
The child shall
				be canceled from the program as of the first day of the month following the
				month in which the department is notified that the child has other health
				insurance coverage. If there are months during which the child is covered by
				both another insurance plan and the hawki program, the other insurance plan
				shall be the primary payor and hawki shall be the payor of last
				resort.
(7)
Admission to a
				public institution.
The child shall be canceled from the program if
				the child is in a public institution at the time of the annual
				review.
(8)
Admission to an
				institution for mental disease.
The child shall be canceled from the
				program if the child is a patient in an institution for mental disease at the
				time of annual review.
(9)
Employment with the state of Iowa.
The child shall be canceled
				from the hawki program as of the first day of the month in which the child's
				parent became eligible to participate in a health or dental plan available to
				state of Iowa employees.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 86 - Healthy and Well Kids in Iowa (HAWK-I) Program › Rule 441-86.8 - Premiums and Copayments

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Income considered.
The income considered in determining the
				premium amount shall be the family's countable income using the modified
				adjusted gross income methodology.
(2)
Premium amount.
Except
				as specified for supplemental dental-only coverage in subrule 86.20(3),
				premiums under the HAWK-I program shall be assessed as follows:
a. No premium is charged if:
(1) The eligible child is an American Indian
				or Alaskan Native; or
(2) The
				family's countable income is less than 181 percent of the federal poverty level
				for a family of the same size.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 86 - Healthy and Well Kids in Iowa (HAWK-I) Program › Rule 441-86.9 - Annual Reviews of Eligibility

Current through Register Vol. 47, No. 3, July 24, 2024
All eligibility factors shall be reviewed at least every 12
				  months to establish ongoing eligibility for the program. "Month one" shall be
				  the first month in which coverage is provided.
(1)
Review form.
A
				prepopulated review form on which the answers, except for income, have been
				completed based on the information on file shall be sent to the family. The
				family shall review the completed information for accuracy and fill in the
				income section of the form. If family income cannot be verified through
				electronic data matches, the family shall be required to provide verification
				of current income. The family shall sign and date the form attesting to its
				accuracy as part of the review process.
(2)
Failure to provide
				information.
The child shall not be enrolled for the next 12-month
				period if the family fails to provide information and verification of income or
				otherwise fails to cooperate in the annual review process. If the completed
				review form and any information necessary to establish continued eligibility
				are received within 14 calendar days of the end of an enrollment period, the
				review form and information shall be acted upon as though they had been
				received timely. If the fourteenth calendar day falls on a weekend or state
				holiday, the enrollee shall have until the next business day to provide the
				review form and any information necessary to establish continued
				eligibility.
(3)
Change in
				plan.
Rescinded IAB 1/13/10, effective 3/1/10.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 86 - Healthy and Well Kids in Iowa (HAWK-I) Program › Rule 441-86.11 - Notice Requirements

Current through Register Vol. 47, No. 3, July 24, 2024
The applicant shall be provided an adequate written notice of
				  the decision regarding the applicant's eligibility for the HAWK-I program. The
				  enrollee shall be notified in writing of any decision that adversely affects
				  the enrollee's eligibility or the amount of benefits. The notice shall be
				  timely and adequate as provided in rule 441-16.3 (17A).
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 86 - Healthy and Well Kids in Iowa (HAWK-I) Program › Rule 441-86.12 - Appeals and Fair Hearings

Current through Register Vol. 47, No. 3, July 24, 2024
If the applicant or enrollee disputes a decision to reduce,
				  cancel or deny participation in the HAWK-I program, the applicant or enrollee
				  may appeal the decision in accordance with 441-Chapter 7.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 86 - Healthy and Well Kids in Iowa (HAWK-I) Program › Rule 441-86.14 - Covered Services

Current through Register Vol. 47, No. 3, July 24, 2024
The benefits provided under the hawki program shall meet a
				  benchmark, benchmark equivalent, or benefit plan that complies with Title XXI
				  of the federal Social Security Act.
(1)
Required medical
				services.
The participating health plan shall cover at a minimum the
				following medically necessary services:
a.
				Inpatient hospital services (including medical, surgical, intensive care unit,
				mental health, and substance abuse services).
b. Physician services (including surgical and
				medical, and including office visits, newborn care, well-baby and well-child
				care, immunizations, urgent care, specialist care, allergy testing and
				treatment, mental health visits, and substance abuse visits).
c. Outpatient hospital services (including
				emergency room, surgery, lab, and x-ray services and other services).
d. Ambulance services.
e. Physical therapy.
f. Nursing care services (including skilled
				nursing facility services).
g.
				Speech therapy.
h. Durable medical
				equipment.
i. Home health
				care.
j. Hospice
				services.
k. Prescription
				drugs.
l. Rescinded lAB 1/13/10,
				effective 3/1/10.
m. Hearing
				services.
n. Vision services
				(including corrective lenses).
o.
				Translation and interpreter services as specified pursuant to
				42 U.S.C. Section
				1397ee(a)(1).
p. Chiropractic services.
q. Occupational therapy.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 86 - Healthy and Well Kids in Iowa (HAWK-I) Program › Rule 441-86.15 - Participating Health and Dental Plans

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Licensure.
The
				participating health or dental plan must:
a.
				Be licensed by the division of insurance of the department of commerce to
				provide health or dental care coverage in Iowa; or
b. Be an organized delivery system licensed
				by the director of public health to provide health or dental care
				coverage.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 86 - Healthy and Well Kids in Iowa (HAWK-I) Program › Rule 441-86.16 - Clinical Advisory Committee

Current through Register Vol. 47, No. 3, July 24, 2024
Members of the clinical advisory committee established in
				  accordance with the provisions of 441-paragraph 1.10(2)
"c"
shall be appointed to three-year terms. Members may be appointed for more than
				  one term. No more than one-third of the membership of the committee shall
				  rotate off the committee in any given calendar year.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 86 - Healthy and Well Kids in Iowa (HAWK-I) Program › Rule 441-86.17 - Use of Donations to the Hawk-i Program

Current through Register Vol. 47, No. 3, July 24, 2024
If an individual or other entity makes a monetary donation to
				  the HAWK-I program, the department shall deposit the donation into the HAWK-I
				  trust fund. The department shall track all donations separately and shall not
				  commingle the donations with other moneys in the trust fund. The department
				  shall report the receipt of all donations to the HAWK-I board.
(1) If the donor specifically identifies the
				purpose of the donation, regardless of the amount, the donation shall be used
				as specified by the donor as long as the identified purpose is permissible
				under state and federal law.
(2) If
				the donation is less than $5,000 and the donor does not specifically identify
				how it is to be used, the department shall use the moneys in the following
				order:
a. For the direct benefit of enrollees
				(e.g., premium payments).
b. For
				outreach activities.
c. For other
				purposes as determined by the HAWK-I board.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 86 - Healthy and Well Kids in Iowa (HAWK-I) Program › Rule 441-86.18 - Health Insurance Data Match Program

Current through Register Vol. 47, No. 3, July 24, 2024
All carriers, as defined in Iowa Code section
				  514C.13,
				  shall enter into an agreement with the department to provide data necessary to
				  allow the department to comply with the mandate of Iowa Code section
				  505.25.
				  Each carrier shall either:
1. Enter
				into and maintain an agreement with the department on Form 470-4435, HAWK-I
				Data Use Agreement; or
2. Provide
				proof of an existing agreement with the department or the department's
				designee.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 86 - Healthy and Well Kids in Iowa (HAWK-I) Program › Rule 441-86.19 - Recovery

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Definitions.
"Administrative error"
means an action of
				  the department that results in incorrect payment of benefits, including
				  premiums paid to a health or dental plan, due to one or more of the following
				  circumstances:
1. Misfiled or lost
				form or document.
2. Error in
				typing or copying.
3. Computer
				input error
4. Mathematical
				error
5. Failure to determine
				eligibility correctly when all essential information was available to the
				department.
6. Failure to request
				essential verification necessary to make an accurate eligibility
				determination.
7. Failure to make
				timely revision in eligibility following a change in policy requiring
				application of the policy change as of a specific date.
8. Failure to issue timely notice to cancel
				benefits that results in benefits continuing in error.
"Client error "
means any action or inaction
				  of the enrollee or the enrollee's representative that results in incorrect
				  payment of benefits, including premiums paid to a health or dental plan,
				  because at least one of the following occurred:
1. The enrollee or the enrollee's
				representative failed to disclose information or gave a false or misleading
				statement, oral or written, regarding income or another eligibility factor;
				or
2. The enrollee or the
				enrollee's representative failed to timely report a change as defined in rule
				441-86.10(5141).
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 86 - Healthy and Well Kids in Iowa (HAWK-I) Program › Rule 441-86.20 - Supplemental Dental-only Coverage

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Definition.
"Supplemental dental-only coverage"
means
				  dental care coverage provided to a child who meets the eligibility requirements
				  for the hawki program except that the child is covered by health insurance
				  through an individual or group health plan.
(2)
Eligibility.
Unless
				otherwise specified, eligibility for supplemental dental-only coverage shall be
				determined in accordance with the provisions of rules
				441-86.2 (5141) through 441-
				86.12(5141) and 441-86.19 (5141).
(3)
Premiums.
Premiums for
				participation in the supplemental dental-only plan are assessed as follows:
a. No premium is charged to families whose
				countable income is less than or equal to 167 percent of the federal poverty
				level for a family of the same size using the modified adjusted gross income
				methodology or to an eligible child who is an American Indian or Alaska
				Native.
b. If the family's
				countable income is equal to or exceeds 168 percent of the federal poverty
				level but does not exceed 203 percent of the federal poverty level for a family
				of the same size, the premium is $5 per child per month with a $10 monthly
				maximum per family.
c. If the
				family's countable income exceeds 203 percent of the federal poverty level but
				does not exceed 254 percent of the federal poverty level for a family of the
				same size, the premium is $10 per child per month with a $15 monthly maximum
				per family.
d. If the family's
				countable income exceeds 254 percent of the federal poverty level for a family
				of the same size, the premium is $15 per child per month with a $20 monthly
				maximum per family.
e. If the
				family includes uninsured children who are eligible for both medical and dental
				coverage under hawki and insured children who are eligible only for dental
				coverage, the premium shall be assessed as follows:
(1) The total premium shall be no more than
				the amount that the family would pay if all the children were eligible for both
				medical and dental coverage.
(2) If
				the family has one child eligible for both medical and dental coverage and one
				child eligible for dental coverage only, the premium shall be the total of the
				health and dental premium for one child and the dental premium for one
				child.
(3) If the family has two or
				more children eligible for both medical and dental coverage, no additional
				premium shall be assessed for dental-only coverage for the children who do not
				qualify for medical coverage under hawki because they are covered by health
				insurance.
f. The
				provisions of subrules 86.8(3)to 86.8(6) apply to premiums specified in this
				subrule.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 87 - Family Planning Program › Rule 441-87.2 - Eligibility

Current through Register Vol. 47, No. 3, July 24, 2024
Eligibility for the family planning program shall be
				  determined according to the provisions of this rule.
(1)
Persons covered.
Subject
				to funding as described in subrule 87.7(1) and to the requirements of subrules
				87.2(2), 87.2(4), and 87.2(6), assistance for family planning services shall be
				available to the following individuals who are not enrolled in medical
				assistance pursuant to 441-Chapter 74 or 441-Chapter 75:
a. Women who were enrolled in medical
				assistance when their pregnancy ended and who are capable of bearing children
				but are not pregnant. Eligibility for these women extends for 12 consecutive
				months after the month when their 60-day postpartum period ends;
b. Women who are under the age of 55, who are
				capable of bearing children but are not pregnant, and who have household income
				that does not exceed 300 percent of the federal poverty level as determined
				pursuant to subrule 87.2(3);
c. Men
				who are under the age of 55, who are capable of fathering children, and who
				have household income that does not exceed 300 percent of the federal poverty
				level as determined pursuant to subrule 87.2(3).
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 87 - Family Planning Program › Rule 441-87.3 - Enrollment

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Application.
An individual who requests assistance for family
				planning services shall file an application Form 470-5485. A woman eligible
				under paragraph 87.2(1)
"a"
is not required to file an
				application for assistance under this program. The department will
				automatically redetermine eligibility upon loss of other Medicaid eligibility
				within 12 months after the month when the 60-day postpartum period
				ends.
(2)
Place of
				filing.
An application may be filed at any department office or
				authorized Title X family planning agency.
(3)
Information or verification
				needed to determine eligibility.
The department or authorized Title X
				agency, as applicable, shall notify the applicant or member, authorized
				representative, or responsible person in writing of the information or
				verification required to establish eligibility. This notice shall be provided
				to the applicant or member, authorized representative, or responsible person
				personally or by mail or fax.
a. The
				department or authorized Title X agency, as applicable, shall allow the
				applicant or member, authorized representative, or responsible person ten
				calendar days to supply the information or verification requested.
b. The department or authorized Title X
				agency, as applicable, may extend the deadline for a reasonable period of time
				when the applicant or member, authorized representative, or responsible person
				is making reasonable efforts but is unable to secure the required information
				or verification.
c. If benefits are
				denied for failure to provide information or verification and the information
				or verification is provided within 14 calendar days of the effective date of
				the denial, the department or authorized Title X agency, as applicable, shall
				complete the eligibility determination as though the information or
				verification were received timely. If the fourteenth calendar day falls on a
				weekend or state holiday, the applicant or member, authorized representative,
				or responsible person shall have until the next business day to provide the
				information.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 87 - Family Planning Program › Rule 441-87.4 - Effective Date of Eligibility

Current through Register Vol. 47, No. 3, July 24, 2024
Subject to the availability of funding appropriated for this
				  purpose, assistance for family planning services under this program shall be
				  effective on the first day of the month of application or the first day of the
				  month in which all eligibility requirements are met, whichever is later.
				  Assistance shall not be available under this program for any months prior to
				  the month of application.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 87 - Family Planning Program › Rule 441-87.5 - Period of Eligibility

Current through Register Vol. 47, No. 3, July 24, 2024
Eligibility for family planning services under this program
				  shall be limited to a period of 12 months from the effective date of
				  eligibility, or the duration of appropriated funding, whichever is less. A new
				  application or annual redetermination of eligibility shall be required for
				  benefits to continue beyond 12 months.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 87 - Family Planning Program › Rule 441-87.6 - Reporting Changes

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Required changes to report.
An individual applying for or
				receiving family planning services under this program shall report the
				following changes within ten days from the date the change is known:
a. Change in mailing address;
b. No longer a resident of Iowa;
c. A woman becomes pregnant;
d. No longer capable of bearing or fathering
				children;
e. Becomes Medicaid or
				Iowa health and wellness plan eligible, except women meeting criteria in
				paragraph 87.2(1)
"a"
; or
f. Turns 55 years of age.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 87 - Family Planning Program › Rule 441-87.7 - Funding of Family Planning Services Program

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Distribution of funds.
Distribution of family planning services program funds shall be made to
				eligible, approved, and participating family planning providers subject to rule
				441-87.11
				(217). Eligible family planning providers shall not include any provider that
				performs abortions or that maintains or operates a facility where abortions are
				performed and must attest to this fact. Effective July 1, 2018, eligible family
				planning providers shall be interpreted to include a distinct location of a
				nonprofit health care delivery system, if the distinct location provides family
				planning services but does not perform abortions or maintain or operate as a
				facility where abortions are performed. For the purposes of this subrule,
				"nonprofit health care delivery system" means an Iowa nonprofit corporation
				that controls, directly or indirectly, a regional health care network
				consisting of hospital facilities and various ambulatory and clinic locations
				that provide a range of primary, secondary, and tertiary inpatient, outpatient,
				and physician services. For the purposes of this subrule, "abortion" does not
				include any of the following:
a. The
				treatment of a woman for a physical disorder, physical injury, or physical
				illness, including a life-endangering physical condition caused by or arising
				from the pregnancy itself, that would, as certified by a physician, place the
				woman in danger of death.
b. The
				treatment of a woman for a spontaneous abortion, commonly known as a
				miscarriage, when not all of the products of human conception are
				expelled.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 87 - Family Planning Program › Rule 441-87.8 - Availability of Services

Current through Register Vol. 47, No. 3, July 24, 2024
Family planning services are payable for an individual
				  enrolled in this program only when care is received at or authorized by a
				  participating family planning provider.
(1) Sterilization is a covered service
				subject to the limitations in 441-Chapter 78.
(2) Covered services shall not include
				abortion services.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 87 - Family Planning Program › Rule 441-87.9 - Payment of Covered Services

Current through Register Vol. 47, No. 3, July 24, 2024
Payment for family planning services covered under this
				  chapter, including services authorized but not provided by a participating
				  family planning provider, shall be made only to participating family planning
				  providers on a fee schedule determined by the department. Family planning
				  services program funds distributed in accordance with this rule shall not be
				  used for direct or indirect costs, including but not limited to administrative
				  costs or expenses, overhead, employee salaries, rent, and telephone and other
				  utility costs, related to providing abortions as specified in subrule
				  87.7(1).
(1)
Fee
				schedule.
The fee schedule shall include the amount of payment for
				each service and any limits on the service (e.g., a routine Pap smear is
				payable once annually).
(2)
Third-party payments.
This program is the payer of last resort
				for services covered in this chapter. Any third-party payment received by the
				family planning agency or other provider of services plus any payments under
				this program cannot exceed the fee schedule allowance.
(3)
Supplementation.
Payment
				made under this program shall be considered payment in full.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 87 - Family Planning Program › Rule 441-87.10 - Submission of Claims

Current through Register Vol. 47, No. 3, July 24, 2024
(1) Family
				planning providers that participate in the program shall submit claims to Iowa
				Medicaid for services rendered no later than 45 days from the last day of the
				month in which services were provided.
(2) Following a successful review of the
				claim, the Iowa Medicaid enterprise shall make payments to the family planning
				provider subject to the availability of funding and the allocation of available
				funds under subrule 87.7(1).
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 87 - Family Planning Program › Rule 441-87.11 - Providers Eligible to Participate

Current through Register Vol. 47, No. 3, July 24, 2024
(1) Providers
				must be enrolled with the Iowa Medicaid program, subject to 441-Chapter 79, and
				otherwise qualified to provide family planning services under Medicaid, subject
				to the limitations related to abortions, as specified above under subrule
				87.7(1). Effective July 1, 2018, as a condition of eligibility as a provider
				under the family planning services program, each distinct location of a
				nonprofit health care delivery system shall enroll in the program as a separate
				provider, be assigned a distinct provider identification number, and complete
				an attestation that abortions are not performed at the distinct location. For
				the purposes of this subrule, "nonprofit health care delivery system" shall
				have the same meaning as provided under subrule 87.7(1).
(2) Process for enrollment. Providers wishing
				to enroll under the state family planning program must complete the following
				steps:
a. Must complete enrollment with Iowa
				Medicaid.
b. Must complete Form
				470-5484 regarding nonprovision of abortions, pursuant to requirements
				referenced above under subrule 87.7(1).
c. Forms referenced in this subrule must be
				sent to Iowa Medicaid, Provider Enrollment Unit, P.O. Box 36450, Des Moines,
				Iowa 50315.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 88 - Specialized Managed Care Programs › Rule 441-88.2 - Participation

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Contracts with PHPs.
The department shall enter into contracts
				for the scope of services specified in 441-Chapter 78, or a part thereof, with
				a PHP which has verified to the department that the criteria set forth in the
				Social Security Act have been met. This verification shall be reviewed by
				Centers for Medicare and Medicaid Services (CMS) staff to ensure that the
				status of PHP is rightfully conferred. The department may also include the
				scope of services described in 441-Chapter 74, known as the Iowa Health and
				Wellness Plan, or part thereof, in contracts with PHPs.
a. The department shall also determine that
				the PHP meets the following additional requirements:
(1) The PHP shall make the services it
				provides to enrolled recipients at least as accessible (in terms of timeliness,
				duration, and scope) to them as those services are accessible to recipients in
				the enrollment area who are not enrolled.
(2) The PHP shall provide satisfaction to the
				department that insolvency is not likely to occur and that enrolled Medicaid
				recipients shall not be responsible for its debts if the PHP should become
				insolvent.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 88 - Specialized Managed Care Programs › Rule 441-88.5 - Covered Services

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Amount, duration, and scope of services.
Except as provided
				for in the contract, PHPs shall cover as a minimum all services covered by the
				Medicaid program as set forth in 441-Chapter 78.
(2)
Mandatory services.
a. Although the contract may specify
				additional services covered (with the exception of those defined in 88.5(3)),
				the PHP shall cover as a minimum the following services:
(1) Inpatient hospital services.
(2) Outpatient hospital services.
(3) Physician services.
(4) Family planning services.
(5) Home health agency services.
(6) Laboratory and X-ray services.
(7) Early periodic screening, diagnosis and
				treatment for persons under age 21.
(8) Rural health clinic services (where
				available).
(9) Advanced registered
				nurse practitioners.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 88 - Specialized Managed Care Programs › Rule 441-88.6 - Emergency Services

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Availability of services.
The PHP will ensure that the
				services of a primary care physician are available on an emergency basis 24
				hours a day, seven days a week, either through the PHP's own providers or
				through arrangements with other providers. In addition, the PHP must provide
				payment to nonparticipating providers within 60 days of receipt of the bill for
				all contracted services furnished by providers which do not have contractual
				arrangements with the PHP to provide services but which were needed immediately
				because of an injury or illness and in which case the illness or injury did not
				permit a choice of provider.
(2)
PHP payment liability.
PHP payment liability on account of
				injury or emergency illness is limited to emergency care required before the
				recipient can, without medically harmful consequences, return to the enrollment
				area or to the care of a provider with whom the PHP has arrangements to provide
				services. If an ambulance is necessary to transport the recipient to follow-up
				treatment, the PHP shall be financially liable. Benefits for continuing the
				follow-up treatment are provided only in the PHP's enrollment area.
If an enrolled recipient is injured or becomes ill and
				  receives emergency services outside the PHP's enrollment area, the PHP shall
				  pay the facility or person who provided the emergency care for emergency
				  medical services and medical services, for inpatient hospital services in a
				  general hospital as a result of the emergency, and for emergency ambulance
				  service.
(3)
Notification and claim filing time span.
The PHP may set
				notification and claim filing time limitations in the event of the provision of
				care by nonparticipating providers. However, failure to give notice or to file
				claims within those time limitations will not invalidate any claim if it can be
				shown that it was not reasonably possible to give the notice and that notice
				was, in fact, given as soon as was reasonably possible.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 88 - Specialized Managed Care Programs › Rule 441-88.7 - Access to Service

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Choice of provider.
Recipients will have the opportunity to
				choose their health care professionals to the extent possible and medically
				appropriate from any of the PHP providers participating in the Medicaid
				contract.
(2)
Medical
				service delivery sites.
Medical service delivery sites shall have the
				following specific characteristics:
a. Be
				located within 30 miles of and be accessible from the personal residences of
				enrolled recipients.
b. Have
				sufficient staff resources to adequately provide the medical services for which
				the contract is in effect including physicians with privileges at one or more
				acute care hospitals.
c. Have
				arrangements for services to be provided by other providers where in-house
				capability to serve specific medical needs does not exist.
d. Meet the applicable standards for
				participating in the Medicaid program.
e. Be in compliance with all applicable
				local, state, and federal standards related to the service provided as well as
				those for fire and safety.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 88 - Specialized Managed Care Programs › Rule 441-88.8 - Grievance Procedures

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Written procedure.
The PHP must have a written procedure by
				which enrolled recipients may express grievances, complaints, or
				recommendations, either individually or as a class and which:
a. Is approved by the department prior to
				use.
b. Acknowledges receipt of a
				grievance to the grievant.
c. Sets
				time frames for resolution including emergency procedures which are appropriate
				to the nature of the grievance and which require that all grievances shall be
				resolved within 30 days.
d. Ensures
				the participation of persons with authority to require corrective
				action.
e. Includes at least one
				level of appeal.
f. Ensures the
				confidentiality of the grievant.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 88 - Specialized Managed Care Programs › Rule 441-88.9 - Records and Reports

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Medical records system.
The PHP shall comply with the
				provisions of rule
				441-79.3
				(249A) regarding maintenance and retention of clinical and fiscal records and,
				in addition, the PHP must maintain a medical record system which:
a. Identifies each medical record by the
				departmentally assigned state identification number.
b. Identifies the location of every medical
				record.
c. Places medical records
				in a given order and location.
d.
				Provides a specific medical record on demand.
e. Maintains the confidentiality of medical
				records information and releases the information only in accordance with
				established policy pursuant to subrule 88.9(3).
f. Maintains inactive medical records in a
				specific place.
g. Permits
				effective professional review in medical audit processes.
h. Facilitates an adequate system for
				follow-up treatment including monitoring and follow-up of off-site referrals
				and inpatient stays.
i. Meets state
				and federal reporting requirements applicable to PHPs.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 88 - Specialized Managed Care Programs › Rule 441-88.10 - Marketing

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Marketing procedures.
All marketing plans, procedures, and
				materials used by the PHP must be approved in writing by the department prior
				to use. Random door-to-door marketing of low-income families or the offering of
				financial incentives will not be approved.
(2)
Marketing
				representatives.
Marketing representatives utilized to market Medicaid
				recipients must be sufficiently trained and capable of performing marketing
				activities within the requirements of the contract. The PHP's marketing
				representatives must represent the PHP in an honest and straightforward manner.
				In its marketing presentations, the PHP must include information which ensures
				that the representative is not mistaken for a department employee. Marketing
				presentations which intentionally belittle or maliciously downplay the benefit
				package, services, or providers of another participating managed health care
				option will not be approved.
(3)
Marketing presentations.
The PHP may make marketing
				presentations in the local office(s) of the department or otherwise include the
				department in marketing efforts at the discretion of the department.
(4)
Marketing materials.
Written material must include a marketing brochure or a member handbook which
				fully explains the services available, how and when to obtain them, and special
				factors applicable to enrolled recipients as specified in the
				contract.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 88 - Specialized Managed Care Programs › Rule 441-88.11 - Patient Education

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Use of services.
The PHP shall have procedures in effect to
				orient enrolled recipients in the use of services the PHP is contracting to
				provide. This includes what to do if the recipient requires medical care while
				out of the enrollment area, a 24-hour-a-day telephone number, appropriate use
				of the referral system, grievance procedures, and how emergency treatment is to
				be provided.
(2)
Patient
				rights and responsibilities.
The PHP shall have in effect a written
				statement of patient rights and responsibilities which is available upon
				request as well as issued to all new enrolled recipients. This statement may be
				part of an informational brochure provided to all new enrollees. The right of
				the enrolled recipient to request disenrollment must be included.