reglab/statecodes huggingface dataset:
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 73 - Managed Care › Rule 441-73.8 - Access to Service

Current through Register Vol. 47, No. 3, July 24, 2024
(1) The MCP
				shall ensure enrollees have access to services as specified in the contract. In
				general, the MCP shall provide available, accessible, and adequate numbers of
				institutional facilities, service locations, and service sites and
				professional, allied, and paramedical personnel for the provision of covered
				services, including all emergency services, on a 24-hours-a-day,
				seven-days-a-week basis. At a minimum, access to services shall comply with the
				standards described in the contract. For areas of the state where provider
				availability is insufficient to meet these standards, for example, in health or
				dental professional shortage areas and medically underserved areas, the access
				standards shall meet the usual and customary standards for the community.
				Exceptions to the requirements contained in this rule shall be justified and
				documented to the state on the basis of community standards. All other services
				not specified in this rule shall meet the usual and customary standards for the
				community.
(2) Choice of providers.
				An enrollee shall use the MCP's provider network unless the MCP has authorized
				a referral to a nonparticipating provider for provision of a service or
				treatment plan or as specified for provision of emergency services set forth in
				rule 441-73.7 (249A). In accordance
				with federal funding requirements, including
				42 CFR
				431.51(b)(2) as amended to
				July 19, 2022, the managed care organization shall allow enrollees freedom of
				choice of providers of any department-enrolled family planning service provider
				including those providers who are not in the MCP network.
(3) Continuity of care. The MCP shall have
				policies and procedures that provide for the continuity of care of treatment to
				ensure that a new enrollee's existing services are honored as required in the
				contract.
(4) Adequate service
				referral support and after-hours call-in coverage. The MCP shall ensure
				enrollee access to service information and medical coverage 24 hours a day, 7
				days a week, 365 days a year.
a.
Member helpline.
The MCP shall maintain a dedicated toll-free
				member services helpline as established in the contract to handle a variety of
				member inquiries and to provide warm transfer of enrollees to outside entities,
				such as provider offices, and to internal MCP departments, such as care
				coordinators.
b.
Nurse call
				line.
The managed care organization shall operate a toll-free nurse
				call line that provides nurse triage telephone services for members to receive
				medical advice 24 hours a day, seven days a week from trained medical
				professionals.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 73 - Managed Care › Rule 441-73.9 - Incident Reporting

Current through Register Vol. 47, No. 3, July 24, 2024
(1) The managed
				care organization shall develop and implement a critical incident reporting and
				management system for participating providers in accordance with the department
				requirements for reporting incidents for Section 1915(c) HCBS waivers, for the
				Section 1915(i) habilitation program, and as required for licensure of programs
				through the department of inspections and appeals.
(2) The managed care organization shall
				develop and implement policies and procedures, subject to department review and
				approval, to:
a. Address and respond to
				incidents;
b. Report incidents to
				the appropriate entities in accordance with required time frames; and
c. Track and analyze incidents.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 73 - Managed Care › Rule 441-73.10 - Discharge Planning

Current through Register Vol. 47, No. 3, July 24, 2024
The managed care organization shall establish policies and
				  procedures, subject to approval by the department, that protect an individual
				  from involuntary discharge that may lead to placement in an inappropriate or
				  more restrictive setting. The managed care organization shall facilitate a
				  seamless transition whenever a member transitions between facilities or
				  residences.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 73 - Managed Care › Rule 441-73.11 - Level of Care Assessment and Annual Reviews

Current through Register Vol. 47, No. 3, July 24, 2024
The managed care organization shall establish policies and
				  procedures to ensure the implementation of level of care and needs-based
				  eligibility assessments and reassessments as required in the contract and
				  consistent with the department's level of care and needs-based eligibility
				  assessment process and the requirements provided in 441-Chapters 75, 78, 81,
				  82, 83, and 85. Waiver level of care determinations must be consistent with
				  those made for the appropriate institutional level of care under the state
				  plan.
(1) Initial level of care
				assessment. Managed care organizations are responsible for conducting level of
				care and needs-based eligibility assessments for a current enrollee who
				requires a level of care or a needs-based eligibility assessment. The managed
				care organization shall perform the assessment using department-approved
				assessment tools. The results of the assessment shall be submitted to the Iowa
				Medicaid medical services unit for determination of level of care or
				needs-based eligibility.
(2) Annual
				continued stay reviews, continued care reviews and redeterminations. When an
				enrollee requires a continued stay review, a continued care review or a
				redetermination, the managed care organization shall use department-approved
				assessment tools. If the managed care organization becomes aware that the
				enrollee's functional or medical status has changed in a way that may affect
				the enrollee's level of care or needs-based eligibility, the managed care
				organization shall submit the assessment findings to the Iowa Medicaid medical
				services unit for determination of level of care or needs-based
				eligibility.
(3) At any time, if
				the managed care organization becomes aware that the enrollee's functional or
				medical status has changed in a way that may affect level of care or
				needs-based eligibility, the managed care organization shall conduct a level of
				care or needs-based assessment using the department-approved tools and submit
				the assessment to the Iowa Medicaid medical services unit for determination of
				level of care or needs-based eligibility.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 73 - Managed Care › Rule 441-73.12 - Appeal of Mcp Actions

Current through Register Vol. 47, No. 3, July 24, 2024
The MCPs shall have written appeal policies and procedures
				  for an enrollee, or an enrollee's authorized representative, to appeal an MCP
				  action. The policies must address contractual requirements and federal funding
				  requirements, including 42
				  CFR 438, Subpart F, as amended to July 19,
				  2022.
(1)
MCP appealable
				actions.
MCP actions that may be appealed include:
a. Denial or limited authorization of a
				requested service, including the type or level of service.
b. Reduction, suspension, or termination of a
				previously authorized service.
c.
				Denial, in whole or in part, of payment of service.
d. Failure to provide services in a timely
				manner as described by the department.
e. Failure to act within the required time
				frames set forth in federal funding requirements, including
				42 CFR
				438.408(b) as amended July
				19, 2022.
f. For a resident of a
				rural area who has only one appropriate provider of a needed service, the
				denial of an enrollee's request to exercise the enrollee's right to obtain
				services outside of the MCO's network.
g. The denial of an enrollee's request to
				dispute a financial liability, including cost sharing, copayments, premiums,
				deductibles, coinsurance, and other enrollee financial liabilities.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 73 - Managed Care › Rule 441-73.13 - Appeal to Department

Current through Register Vol. 47, No. 3, July 24, 2024
If the enrollee is not satisfied with the final decision
				  rendered by the MCP through the managed care plan's appeal process, the
				  enrollee may appeal an action in accordance with the appeal process available
				  to all persons receiving Medicaid-funded services as set forth in 441-Chapter
				  7.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 73 - Managed Care › Rule 441-73.14 - Continuation of Benefits

Current through Register Vol. 47, No. 3, July 24, 2024
The MCP shall be required to continue the member's benefits
				  during the appeal in accordance with federal funding requirements, including
				  42 CFR
				  438.420 as amended to July 19, 2022.
(1) If the benefits are continued or
				reinstated while the appeal is pending, the benefits must be continued until
				one of the following occurs:
a. The enrollee
				withdraws the appeal request;
b.
				Ten days pass after the MCP mailed the notice providing the resolution of the
				appeal against the enrollee, unless the enrollee, within the ten-day time
				frame, requests a state fair hearing with continuation of benefits until a
				state fair hearing decision is reached; or
c. The time period or service limits of a
				previously authorized service are met.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 73 - Managed Care › Rule 441-73.15 - Grievances

Current through Register Vol. 47, No. 3, July 24, 2024
The MCP shall have policies and procedures for review of any
				  nonclinical incidents, nonclinical complaints, or nonclinical concerns.
				  Grievances may be communicated verbally or in writing and require that the
				  review be conducted by someone other than the person or persons involved in the
				  grievance. All policies related to the review of grievances shall be approved
				  by the department prior to implementation.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 73 - Managed Care › Rule 441-73.16 - Written Record

Current through Register Vol. 47, No. 3, July 24, 2024
All MCP enrollee appeals and grievances shall be logged and
				  reported to the department. The log shall include the status and resolution of
				  all appeals and grievances.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 73 - Managed Care › Rule 441-73.17 - Information Concerning Procedures Relating to the Review of Mcp Decisions and Actions

Current through Register Vol. 47, No. 3, July 24, 2024
The MCP's written procedures for the review of MCP's
				  decisions and actions shall be provided to each new enrollee, to participating
				  providers in a provider manual, and to nonparticipating providers upon
				  request.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 73 - Managed Care › Rule 441-73.18 - Records and Reports

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Records system.
The MCPs shall document and maintain clinical
				and fiscal records in accordance with federal and state requirements, including
				441-Chapter 79 and 42 CFR
				456 as amended to July 19, 2022, throughout
				the course of the contract. The records system shall:
a. Identify transactions with or on behalf of
				each enrollee by the state identification number assigned to the enrollee by
				the department.
b. Provide a
				rationale for, and documentation of, decisions made by the MCP based upon
				medical necessity.
c. Permit
				effective professional review for medical audit processes.
d. Facilitate an adequate system for
				monitoring treatment reimbursed by the managed care organization including
				follow up of the implementation of discharge plans and referral to other
				providers.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 73 - Managed Care › Rule 441-73.19 - Audits

Current through Register Vol. 47, No. 3, July 24, 2024
The department or its designee and the U.S. Department of
				  Health and Human Services (HHS) may evaluate through inspections or other means
				  the quality, appropriateness, and timeliness of services performed by the MCP.
				  The department or HHS may audit and inspect any records of an MCP, or the
				  subcontractor of the MCP, that pertain to services performed and the
				  determination of amounts paid under the contract. These records will be made
				  available at times, at places, and in a manner as authorized representatives of
				  the department, its designee or HHS may request.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 73 - Managed Care › Rule 441-73.20 - Marketing

Current through Register Vol. 47, No. 3, July 24, 2024
MCP marketing activities and materials shall comply with
				  applicable laws and regulations regarding marketing by the MCP and contract
				  terms. The department shall approve all marketing materials, which must comply
				  with federal funding requirements, including
				  42 CFR
				  438.10 and
				  42 CFR
				  438.104 as amended to July 19,
				  2022.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 73 - Managed Care › Rule 441-73.21 - Enrollee Education

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Use
				of services.
The MCP shall provide written information to all
				enrollees on the use of services the MCP is responsible to arrange, monitor,
				and reimburse. Information must include the array of services covered; how to
				access covered services; the providers participating; an explanation of the
				process for the review of MCP decisions and actions, including the enrollee's
				right to a fair hearing under 441-Chapter 7 and how to access that fair hearing
				process; provision of after-hours and emergency care; procedures for notifying
				enrollees of a change in benefits or office sites; how to request a change in
				providers; a statement of consumer rights and responsibilities; out-of-area use
				of service information; availability of toll-free telephone information and
				crisis assistance; and the appropriate use of the referral system.
(2)
Outreach to members with special
				needs.
The MCP shall provide enhanced outreach to members with special
				needs including, but not limited to, persons with a psychiatric disability, an
				intellectual disability or other cognitive impairments; illiterate persons;
				non-English-speaking persons; and persons with visual impairments or who are
				deaf or hard of hearing.
(3)
Patient rights and responsibilities.
The MCP shall have in
				effect a written statement of patient rights and responsibilities that is
				available upon request as well as issued to all new enrollees. This statement
				shall be part of the packet of enrollment information provided to all new
				enrollees.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 73 - Managed Care › Rule 441-73.22 - Payment to the Mcp

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Capitation rate.
In consideration for all services rendered by
				an MCP under a contract with the department, the MCP will receive a payment
				each month for each enrolled member. The monthly reimbursement may be reduced
				by amounts withheld for pay-for-performance components of the contract. The
				withheld amounts will be distributed based on the terms described in the
				managed care contract. Additionally, the department will make an allowance for
				obligations resulting from Section 9010 of the Patient Protection and
				Affordable Care Act, the health insurance providers fee. This capitation rate,
				inclusive of the amounts withheld and the health insurance providers fee,
				represents the total obligation of the department with respect to the costs of
				medical care and services provided to enrolled members under the contract
				except as otherwise designated in the contract rate. Pay-for-performance terms
				will allow for incentive reimbursement if the MCP meets metrics described in
				the MCP contract.
(2)
Determination of rate.
The actuarially sound capitation rate
				will be determined according to the terms of federal funding requirements,
				including 42 CFR
				438.6 as amended to July 19, 2022, Actuarial
				Standards of Practice 49, and other related CMS regulations and generally
				accepted actuarial principles and practices.
(3)
Third-party liability.
If an enrolled member has health insurance coverage or a responsible party
				other than the Medicaid program available for payment of medical or dental
				expenses, it is the right and responsibility of MCP to investigate these
				third-party resources and attempt to obtain payment.
a. The MCP shall have a time limit to attempt
				to collect from third-party resources. The time limit shall be determined by
				the department.
b. The MCP shall
				retain all funds collected from third-party resources during the time
				limit.
c. A complete record of all
				third-party collections must be maintained and made available to the department
				on request.
d. In the event that
				the MCP no longer contracts with the department, the department has the right
				to seek recovery of any third-party collections not collected by the time the
				contract ends and retain the funds. This includes but is not limited to
				subrogation cases.
e. The
				department has the right to retain all funds collected from third-party
				resources after the MCP time limit.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 73 - Managed Care › Rule 441-73.23 - Claims Payment by the Mcp

Current through Register Vol. 47, No. 3, July 24, 2024
(1) The managed
				care organizations shall pay or deny:
a.
				Ninety percent of all clean claims within 30 calendar days of
				receipt,
b. Ninety-nine point five
				percent of all clean claims within 90 calendar days of receipt, and
c. Ninety-five percent of all claims within
				45 calendar days of receipt.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 73 - Managed Care › Rule 441-73.25 - Certifications and Program Integrity

Current through Register Vol. 47, No. 3, July 24, 2024
The MCP shall develop and implement policies, procedures and
				  a mandatory compliance plan to ensure compliance with the contract requirements
				  for certification, program integrity and prohibited affiliations. The MCP shall
				  cooperate and collaborate with the department on all program integrity
				  activities. The MCP shall comply with state and federal laws pertaining to
				  these requirements, including
				  42 CFR
				  438.608 and
				  42 CFR
				  455 as amended to July 19,
				  2022.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 74 - Iowa Health and Wellness Plan › Rule 441-74.1 - Definitions

Current through Register Vol. 47, No. 3, July 24, 2024
The following definitions apply to this chapter in addition
				  to the definitions in 441-Chapter 75.
"Countable income"
means "modified adjusted
				  gross income" (MAGI) or "household income," as applicable, determined pursuant
				  to 42 U.S.C. §
										1396a(e)(14).
"Enrollment period"
means the 12-month
				  period for which Iowa health and wellness plan eligibility is
				  established.
"Essential health benefits"
means the
				  essential health benefits defined at
				  42 U.S.C. §
										18022.
"Iowa dental wellness plan"
means the
				  managed care dental benefit program set forth in 441-Chapter 73.
"Iowa health and wellness plan"
means the
				  medical assistance program set forth in this chapter for individuals with
				  countable income that does not exceed 133 percent of the federal poverty
				  level.
"Iowa wellness plan"
means the benefits and
				  services provided to Iowa health and wellness plan members.
"Managed care organization"
means an entity
				  that (1) is under contract with the department to provide services to Medicaid
				  recipients and (2) meets the definition of "health maintenance organization" as
				  defined in Iowa Code section
				  514B.1.
"Medically exempt individual"
means an
				  individual exempt from mandatory enrollment in an alternative benefit plan
				  pursuant to 42 CFR
				  440.315 as amended to May 16, 2022.
"Minimum essential coverage"
means health
				  insurance defined in Section 5000A(f) of Subtitle D of the Internal Revenue
				  Code.
"Prepaid ambulatory health plan"
has the
				  meaning set forth in 42 CFR
				  438.2 as amended to May 16, 2022.
"Qualified employer-sponsored coverage"
shall be defined pursuant to 42 U.S.C. §
										1396e1(b).
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 74 - Iowa Health and Wellness Plan › Rule 441-74.2 - Eligibility Factors

Current through Register Vol. 47, No. 3, July 24, 2024
Except as more specifically provided in this chapter, Iowa
				  health and wellness plan eligibility shall be determined according to the
				  requirements of 441-Chapter 75.
(1)
Persons covered.
Subject to the additional requirements of
				this chapter and of 441-Chapter 75, medical assistance under the Iowa health
				and wellness plan shall be available to persons 19 through 64 years of age who:
a. Are not eligible for medical assistance in
				a mandatory group under 441-Chapter 75;
b. Have countable income at or below 133
				percent of the federal poverty level for their household size;
c. Are not entitled to or enrolled in
				Medicare benefits under Part A or Part B of Title XVIII of the Social Security
				Act; and
d. Are not pregnant at the
				time of application or reenrollment.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 74 - Iowa Health and Wellness Plan › Rule 441-74.4 - Financial Eligibility

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Countable income.
Individuals are financially eligible for the
				Iowa health and wellness plan if their countable income is no more than 133
				percent of the federal poverty level, as of the date of a decision on initial
				or ongoing eligibility.
(2)
Household size.
For financial eligibility purposes, household
				size shall be determined according to the modified adjusted gross income (MAGI)
				methodology.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 74 - Iowa Health and Wellness Plan › Rule 441-74.5 - Enrollment Period

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Effective dates of eligibility.
Iowa health and wellness plan
				eligibility shall be effective on the first day of the month of application or
				the first day of the month all eligibility requirements are met, whichever is
				later. The enrollment period shall continue for 12 consecutive months unless
				the member is disenrolled in accordance with the provisions of rule
				441-74.8(249A,249N).
(2)
Reinstatement.
Enrollment for the Iowa health and wellness
				plan may be reinstated without a new application in accordance with 441-Chapter
				76.
(3)
Presumptive
				eligibility.
The enrollment period of 12 consecutive months shall not
				apply to individuals temporarily enrolled in Medicaid based on a presumptive
				eligibility determination by a qualified entity in accordance with 441-Chapter
				76.
(4)
Retroactive
				enrollment.
Medical assistance shall be available to a pregnant woman
				or an infant (under one year of age), or a resident of a nursing facility
				licensed under Iowa Code chapter 135C, for all or any of the three months
				preceding the month in which an application is filed when eligibility
				requirements are met in accordance with 441-Chapter 76.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 74 - Iowa Health and Wellness Plan › Rule 441-74.6 - Reporting Changes

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Reporting requirements.
In addition to the reporting
				requirements in 441-Chapter 76, as a condition of ongoing enrollment, a member
				shall report any of the following changes no later than ten calendar days after
				the change takes place:
a. The member enters a
				nonmedical institution, including but not limited to a penal
				institution.
b. The member abandons
				Iowa residency.
c. The member turns
				65.
d. The member becomes entitled
				to or enrolled in Medicare Part A or Part B or both.
e. A child under the age of 21 living with
				the member loses minimum essential coverage if the member is the child's parent
				or caretaker and will claim the child as a dependent for state or federal
				income tax purposes.
f. The member
				is pregnant.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 74 - Iowa Health and Wellness Plan › Rule 441-74.7 - Reenrollment

Current through Register Vol. 47, No. 3, July 24, 2024
A new eligibility determination is required for consecutive
				  12-month enrollment periods. The reenrollment process will follow the
				  requirements in 441-Chapter 76.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 74 - Iowa Health and Wellness Plan › Rule 441-74.8 - Terminating Enrollment

Current through Register Vol. 47, No. 3, July 24, 2024
Iowa health and wellness plan enrollment shall end when any
				  of the following occurs:
1. The
				enrollment period ends and coverage for the next enrollment period has not been
				renewed.
2. The member becomes
				eligible for medical assistance in a mandatory coverage group under 441-Chapter
				75.
3. The member is found to have
				been ineligible for any reason.
4.
				The member dies.
5. The member
				turns 65.
6. The member abandons
				Iowa residency.
7. The member
				becomes entitled to or enrolled in Medicare Part A or Part B or both.
8. A child under the age of 21 living with
				the member loses minimum essential coverage, if the member is the child's
				parent or caretaker and will claim the child as a dependent for state or
				federal income tax purposes.
9. The
				member's countable income exceeds 133 percent of the federal poverty
				level.
10. The Iowa health and
				wellness plan is discontinued according to the requirements in rule
				441-74.14(249A,249N).
11. The
				member does not pay monthly contributions as required by subrule
				74.11(2).
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 74 - Iowa Health and Wellness Plan › Rule 441-74.9 - Recovery

Current through Register Vol. 47, No. 3, July 24, 2024
The department shall recover from a member all Medicaid funds
				  incorrectly expended on behalf of the member in accordance with 441-Chapter
				  75.
(1) The department shall recover
				Medicaid funds expended on behalf of a member from the member's estate in
				accordance with 441-Chapter 75.
(2)
				Funds received from third parties, including Medicare, by a provider other than
				a state mental health institute shall be reported to the department or the
				managed care organization, and an adjustment shall be made to a previously
				submitted claim.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 74 - Iowa Health and Wellness Plan › Rule 441-74.10 - Right to Appeal

Current through Register Vol. 47, No. 3, July 24, 2024
(1) Decisions
				and actions by the department regarding eligibility or services provided under
				this chapter may be appealed to the extent permitted by 441-Chapter
				7.
(2) Members will not be entitled
				to an appeal hearing if the sole basis for denying or limiting services is
				discontinuance of the program pursuant to rule
				441-74.14 (249A,249N).
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 74 - Iowa Health and Wellness Plan › Rule 441-74.11 - Financial Participation

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Copayment.
Payment for nonemergency use of a hospital
				emergency department shall be subject to an $8 copayment by the member, which
				shall be subtracted from the Iowa health and wellness plan payment otherwise
				due to the provider.
(2)
Monthly contributions.
Members enrolled in the Iowa health and
				wellness plan with household income at or above 50 percent of the federal
				poverty level (FPL) are required to pay monthly contributions pursuant to this
				rule.
a.
Monthly contribution
				amount.
The monthly contribution amount for each member is based on
				the countable income of the member's household, determined pursuant to
				441-Chapter 75, as a percentage of the FPL for the household. Monthly
				contribution amounts are as follows:
(1) For a
				member with household income between 50 and 100 percent of the FPL,
				$5;
(2) For a member with household
				income above 100 percent of the FPL, $10.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 74 - Iowa Health and Wellness Plan › Rule 441-74.12 - Benefits and Service Delivery

Current through Register Vol. 47, No. 3, July 24, 2024
Covered benefits and the service delivery method shall be
				  determined by the member's health status.
(1)
Iowa wellness plan
				services.
Members shall be enrolled in the Iowa health and wellness
				plan unless the member is determined by the department to be a medically exempt
				individual.
a. Covered Iowa wellness plan
				services are essential health benefits; all other benefits required pursuant to
				42 U.S.C. §
											1396u-7(b)(1)(B), including
				prescription drugs; and dental services consistent with 441-Chapter
				78.
b. Members enrolled in the Iowa
				health and wellness plan shall be subject to enrollment in managed care, other
				than program for all-inclusive care for the elderly (PACE) programs, pursuant
				to 441-Chapter 73.
c. Dental
				services shall be provided under the Iowa dental wellness plan as set forth in
				441-Chapter 73 through a contract with one or more dental prepaid ambulatory
				health plans. The department may restrict member access to those dental prepaid
				ambulatory health plans with which the department contracts. The dental prepaid
				ambulatory health plan shall provide the member with a dental card identifying
				the member as eligible for dental services.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 74 - Iowa Health and Wellness Plan › Rule 441-74.13 - Claims and Reimbursement Methodologies

Current through Register Vol. 47, No. 3, July 24, 2024
Payment for services provided under the Iowa wellness plan
				  services shall be provided in accordance with 441-Chapter 79 or as provided in
				  a contract between the department or the member's managed care organization and
				  the provider.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 74 - Iowa Health and Wellness Plan › Rule 441-74.14 - Discontinuance of Program

Current through Register Vol. 47, No. 3, July 24, 2024
(1) If the
				methodology for calculating the federal medical assistance percentage for
				eligible individuals, as provided in
				42 U.S.C. §
										1396d(y), is modified
				through federal law or regulation, in a manner that reduces the percentage of
				federal assistance to the state, or if federal law or regulation affecting
				eligibility or benefits for the Iowa wellness plan is modified, the department
				may implement an alternative plan as specified in the medical assistance state
				plan or waiver for coverage of the affected population, subject to prior,
				statutory approval of implementation of the alternative plan.
(2) If the methodology for calculating the
				federal medical assistance percentage for eligible individuals, as provided in
				42 U.S.C. §
										1396d(y), is modified
				through federal law or regulation resulting in a reduction of the percentage of
				federal assistance to the state below 90 percent but not below 85 percent, the
				medical assistance program reimbursement rates for inpatient and outpatient
				hospital services shall be reduced by a like percentage in the succeeding
				fiscal year, subject to prior, statutory approval of implementation of the
				reduction.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 75 - Conditions of Eligibility › Rule 441-75.1 - Persons Covered

Current through Register Vol. 47, No. 3, July 24, 2024
(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.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 75 - Conditions of Eligibility › Rule 441-75.2 - Medical Resources

Current through Register Vol. 47, No. 3, July 24, 2024
Medical resources include health and accident insurance,
				  eligibility for care through the Department of Veterans Affairs, specialized
				  child health services. Title XVIII of the Social Security Act (Medicare), and
				  other resources for meeting the cost of medical care which may be available to
				  the member These resources must be used when reasonably available.
(1) The department shall approve payment only
				for those services or that part of the cost of a given service for which no
				medical resources exist unless pay and chase provisions as defined in rule
				441-75.25 (249A) are
				applicable.
a. Persons who have been approved
				by the Social Security Administration for Supplemental Security Income shall
				complete Form 470-0364, 470-0364(M), 470-0364(MS), or 470-0364(S), SSI Medicaid
				Information, and return it to the department.
b. Persons eligible for Part B of the
				Medicare program shall make assignment to the department on Form 470-0364,
				470-0364(M), 470-0364(MS), or 470-0364(S), SSI Medicaid Information.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 75 - Conditions of Eligibility › Rule 441-75.3 - Acceptance of Other Financial Benefits

Current through Register Vol. 47, No. 3, July 24, 2024
An applicant or member shall take all steps necessary to
				  apply for and, if entitled, accept any income or resources for which the
				  applicant or member may qualify, unless the applicant or member can show an
				  incapacity to do so. Sources of benefits may be, but are not limited to,
				  annuities, pensions, retirement or disability benefits, veterans' compensation
				  and pensions, old-age, survivors, and disability insurance, railroad retirement
				  benefits, black lung benefits, or unemployment compensation.
(1) When it is determined that the
				supplemental security income (SSI)-related applicant or member may be entitled
				to other cash benefits, the department shall send a Notice Regarding Acceptance
				of Other Benefits, Form 470-0383, to the applicant or member
(2) The SSI-related applicant or member must
				express an intent to apply or refuse to apply for other benefits within ten
				calendar days from the date the notice is issued. A signed refusal to apply or
				failure to return the form shall result in denial of the application or
				cancellation of Medicaid unless the applicant or member is mentally or
				physically incapable of filing the claim for other cash benefits.
(3) When the SSI-related applicant or member
				is physically or mentally incapable of filing the claim for other cash
				benefits, the department shall request the person acting on behalf of the
				member to pursue the potential benefits.
(4) The SSI-related applicant or member shall
				cooperate in applying for the other benefits. Failure to timely secure the
				other benefits shall result in cancellation of Medicaid.
Exception: An applicant or member shall not be required to
				  apply for supplementary security income to receive Medicaid under subrule
				  75.1(17).
This rule is intended to implement Iowa Code sections 249A.3
				  and 249A.4.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 75 - Conditions of Eligibility › Rule 441-75.4 - Medical Assistance Lien

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
				When the medical assistance program pays for a member's medical care or
				expenses, the department shall have a lien upon all monetary claims which the
				member may have against third parties for those expenses. Monetary claims shall
				include medical malpractice claims for injuries sustained on or after July 1,
				2011. The lien shall be to the extent of the medical assistance payments only.
a. A lien is not effective unless the
				department files a notice of lien with the clerk of the district court in the
				county where the member resides and with the member's attorney when the
				member's eligibility for medical assistance is established. The notice of lien
				shall be filed before the third party has concluded a final settlement with the
				member, the member's attorney, or other representative.
b. The third party shall obtain a written
				determination from the department concerning the amount of the lien before a
				settlement is deemed final.
(1) A compromise,
				including, but not limited to, notification, settlement, waiver or release of a
				claim, does not defeat the department's lien except pursuant to the written
				agreement of the director or the director's designee under which the department
				would receive less than full reimbursement of the amounts it
				expended.
(2) A settlement, award,
				or judgment structured in any manner not to include medical expenses or an
				action brought by a member or on behalf of a member which fails to state a
				claim for recovery of medical expenses does not defeat the department's lien if
				there is any recovery on the member's claim.
c. All notifications to the department
				required by law shall be directed to the Iowa Medicaid Enterprise, Revenue
				Collection Unit, P.O. Box 36475, Des Moines, Iowa 50315. Notification shall be
				considered made as of the time the notification is deposited so addressed,
				postage prepaid, in the United States Postal Service system.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 75 - Conditions of Eligibility › Rule 441-75.5 - Determination of Countable Income and Resources for Persons in a Medical Institution

Current through Register Vol. 47, No. 3, July 24, 2024
In determining eligibility for any coverage group under rule
				  441-75.1 (249A), certain factors
				  must be considered differently for persons who reside in a medical institution.
				  They are:
(1) Determining income from
				property.
a.
Nontrust
				property.
Where there is nontrust property, unless the document
				providing income specifies differently, income paid in the name of one person
				shall be available only to that person. If payment of income is in the name of
				two persons, one-half is attributed to each. If payment is in the name of
				several persons, including a Medicaid client, a client's spouse, or both, the
				income shall be considered in proportion to the Medicaid client's or spouse's
				interest. If payment is made jointly to both spouses and no interest is
				specified, one-half of the couple's joint interest shall be considered
				available for each spouse. If the client or the client's spouse can establish
				different ownership by a preponderance of evidence, the income shall be divided
				in proportion to the ownership.
b.
Trust property.
Where there is trust property, the payment of
				income shall be considered available as provided in the trust. In the absence
				of specific provisions in the trust, the income shall be considered as stated
				above for nontrust property.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 75 - Conditions of Eligibility › Rule 441-75.6 - Entrance Fee for Continuing Care Retirement Community or Life Care Community

Current through Register Vol. 47, No. 3, July 24, 2024
When an individual resides in a continuing care retirement
				  community or life care community that collects an entrance fee on admission,
				  the entrance fee paid shall be considered a resource available to the
				  individual for purposes of determining the individual's Medicaid eligibility
				  and the amount of benefits to the extent that:
1. The individual has the ability to use the
				entrance fee, or the contract between the individual and the community provides
				that the entrance fee may be used to pay for care should the individual's other
				resources or income be insufficient to pay for such care;
2. The individual is eligible for a refund of
				any remaining entrance fee when the individual dies or when the individual
				terminates the community contract and leaves the community; and
3. The entrance fee does not confer an
				ownership interest in the community.
This rule is intended to implement Iowa Code section
				  249A.4.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 75 - Conditions of Eligibility › Rule 441-75.7 - Furnishing of Social Security Number

Current through Register Vol. 47, No. 3, July 24, 2024
(1) As a condition of eligibility, except as
				provided by subrule 75.7(2), all social security numbers issued to each
				individual (including children) for whom Medicaid is sought must be furnished
				to the department.
(2) The
				requirement of subrule 75.7(1) does not apply to an individual who:
a. Is not eligible to receive a social
				security number;
b. Does not have a
				social security number and may only be issued a social security number for a
				valid nonwork reason in accordance with 20 CFR § 422.104; or
c. Refuses to obtain a social security number
				because of a well-established religious objection. For this purpose, a
				well-established religious objection means that the individual:
(1) Is a member of a recognized religious
				sect or division of the sect; and
(2) Adheres to the tenets or teachings of the
				sect or division of the sect and for that reason is conscientiously opposed to
				applying for or using a national identification number.
(3) If a social security number has not been
				issued or is not known, the individual seeking Medicaid must cooperate with the
				department in applying for a social security number with the Social Security
				Administration or in requesting the Social Security Administration to furnish
				the number.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 75 - Conditions of Eligibility › Rule 441-75.8 - Medical Assistance Corrective Payments

Current through Register Vol. 47, No. 3, July 24, 2024
If a decision by the department or the Social Security
				  Administration following an appeal on a denied application for any of the
				  categories of medical assistance eligibility set forth in rule
				  441-75.1 (249A)
				  is favorable to the claimant, reimbursement will be made to the claimant for
				  any medical bills paid by the claimant during the period between the date of
				  the denial on the initial application and the date regular medical assistance
				  coverage began when the bills were for medical services rendered in the period
				  now determined to be an eligible period based on the following
				  conditions:
(1) These bills must be
				for services covered by the medical assistance program as set forth in
				441-Chapter 78.
(2) Reimbursement
				will be based on Medicaid rates for services in effect at the time the services
				were provided.
(3) If a county
				relief agency has paid medical bills on the recipient's behalf and has not
				received reimbursement through assignment as set forth in 441-Chapter 80, the
				department will reimburse the county relief agency directly on the same basis
				as if the reimbursement was made to the recipient.
(4) Recipients and county relief agencies
				shall file claims for payment under this subrule by submitting Form 470-2224,
				Verification of Paid Medical Bills, to the department. A supply of these forms
				is available from the county office. All requests for reimbursement shall be
				acted upon within 60 days of receipt of all Forms 470-2224 in the county
				office.
(5) Any adverse action
				taken by the department with respect to an application for reimbursement is
				appealable under 441-Chapter 7.
This rule is intended to implement Iowa Code section
				  249A.4.
Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 75 - Conditions of Eligibility › Rule 441-75.9 - Treatment of Medicaid Qualifying Trusts

Current through Register Vol. 47, No. 3, July 24, 2024
(1) A Medicaid qualifying trust is a trust or
				similar legal device established, on or before August 10, 1993, other than by
				will by a person or that person's spouse under which the person may be the
				beneficiary of payments from the trust and the distribution of these payments
				is determined by one or more trustees who are permitted to exercise any
				discretion with respect to the distribution to the person. Trusts or initial
				trust decrees established prior to April 7, 1986, solely for the benefit of a
				mentally retarded person who resides in an intermediate care facility for the
				mentally retarded, are exempt.
(2)
				The amount of income and principal from a Medicaid qualifying trust that shall
				be considered available shall be the maximum amount that may be permitted under
				the terms of the trust assuming the full exercise of discretion by the trustee
				or trustees for the distribution of the funds.
a. Trust income considered available shall be
				counted as income.
b. Trust
				principal (including accumulated income) considered available shall be counted
				as a resource, except where the trust explicitly limits the amount of principal
				that can be made available on an annual or less frequent basis. Where the trust
				limits the amount, the principal considered available over any particular
				period of time shall be counted as income for that period of time.
c. To the extent that the trust principal and
				income is available only for medical care, this principal or income shall not
				be used to determine eligibility. To the extent that the trust is restricted to
				medical expenses, it shall be used as a third party resource.
This rule is intended to implement Iowa Code section
				  249A.4.