Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 75 - Conditions of Eligibility › Rule 441-75.25 - Definitions

Current through Register Vol. 47, No. 3, July 24, 2024
Unless otherwise specified, the definitions in this rule
				  shall apply to 441-Chapters 75 through 85 and 88.
"Aged"
shall mean a person 65 years of age
				  or older.
"Applicant"
shall mean a person who is
				  requesting assistance, including recertification under the medically needy
				  program, on the person's own behalf or on behalf of another person. This also
				  includes parents living in the home with the children and the nonparental
				  relative who is requesting assistance for the children.
"Blind"
shall mean a person with central
				  visual acuity of 20/200 or less in the better eye with use of corrective lens
				  or visual field restriction to 20 degrees or less.
"Break in assistance"
for medically needy
				  shall mean the lapse of more than three months from the end of the medically
				  needy certification period to the beginning of the next current certification
				  period.
"Central office"
shall mean the state
				  administrative office of the department of human services.
"Certification period"
for medically needy
				  shall mean the period of time not to exceed two consecutive months in which a
				  person is conditionally eligible.
"Client"
shall mean all of the
				  following:
1. A Medicaid applicant;
2. A Medicaid member;
3. A person who is conditionally eligible for Medicaid;
				  and
4. A person whose income or assets are considered in
				  determining eligibility for an applicant or member.
"CMAP-related medically needy"
shall mean
				  those individuals under the age of 21 who would be eligible for the child
				  medical assistance program except for excess income or resources.
"Community spouse"
shall mean a spouse of an
				  institutionalized spouse for the purposes of rules
				  441-75.5 (249A),
				  441-75.16 (249A), and
				  441-76.10 (249A).
"Conditionally eligible"
shall mean that a
				  person has completed the application process and has been assigned a medically
				  needy certification period and spenddown amount but has not met the spenddown
				  amount for the certification period or has been assigned a monthly premium but
				  has not yet paid the premium for that month.
"Coverage group"
shall mean a group of
				  persons who meet certain common eligibility requirements.
"Department"
shall mean the Iowa department
				  of human services.
"Disabled"
shall mean a person who is unable
				  to engage in any substantial gainful activity by reason of any medically
				  determinable physical or mental impairment which has lasted or is expected to
				  last for a continuous period of not less than 12 months from the date of
				  application.
"FMAP-related medically needy"
shall mean
				  those persons who would be eligible for the family medical assistance program
				  except for excess income or resources.
"Health insurance"
shall mean protection
				  which provides payment of benefits for covered sickness or injury.
"Incurred medical expenses"
for medically
				  needy shall mean (1) medical bills paid by a client, responsible relative, or
				  state or political subdivision program other than Medicaid during the
				  retroactive certification period or the certification period, or (2) unpaid
				  medical expenses for which the client or responsible relative remains
				  obligated.
"Institutionalized person"
shall mean a
				  person who is an inpatient in a nursing facility or a Medicare-certified
				  skilled nursing facility, who is an inpatient in a medical institution and for
				  whom payment is made based on a level of care provided in a nursing facility,
				  or who is a person described in 75.1(18) for the purposes of rule
				  441-75.5 (249A).
"Institutionalized spouse"
shall mean a
				  married person living in a medical institution, or nursing facility, or home-
				  and community-based waiver setting who is likely to remain living in these
				  circumstances for at least 30 consecutive days, and whose spouse is not in a
				  medical institution or nursing facility for the purposes of rules
				  441-75.5 (249A),
				  441-75.16 (249A), and
				  441-76.10 (249A).
"Local office"
shall mean the county office
				  of the department of human services or the mental health institute or hospital
				  school.
"Medically needy income level (MNIL)"
shall
				  mean 133 1/3 percent of the schedule of basic needs based on family size. (See
				  subrule 75.58(2).)
"Member"
shall mean a person who has been
				  determined eligible for medical assistance under rule
				  441-75.1 (249A). For the
				  medically needy program, "member" shall mean a medically needy person who has
				  income at or less than the medically needy income level (MNIL) or who has
				  reduced countable income to the MNIL during the certification period through
				  spenddown. "Member" may be used interchangeably with "recipient." This
				  definition does not apply to the phrase "household member."
"Necessary medical and remedial services"
for medically needy shall mean medical services recognized by law which are
				  currently covered under the Iowa Medicaid program.
"Noncovered Medicaid services"
for medically
				  needy shall mean medical services that are not covered under Medicaid because
				  the provider was not enrolled in Medicaid, the services are ones which are
				  otherwise not covered under Medicaid, the bill is for a responsible relative
				  who is not in the Medicaid-eligible group or the bill is for services delivered
				  before the start of a certification period.
"Nursing facility services"
shall mean the
				  level of care provided in a medical institution licensed for nursing services
				  or skilled nursing services for the purposes of rule
				  441-75.23 (249A).
"Obligated medical expense"
for medically
				  needy shall mean a medical expense for which the client or responsible relative
				  continues to be legally liable.
"Ongoing eligibility"
for medically needy
				  shall mean that eligibility continues for an SSI-related, CMAP-related, or
				  FMAP-related medically needy person with a zero spenddown.
"Pay and chase"
shall mean that the state
				  pays the total amount allowed under the agency's payment schedule and then
				  seeks reimbursement from the liable third party. The pay and chase provision
				  applies to Medicaid claims for preventive pediatric services and for all
				  services provided to a person for whom there is court-ordered medical
				  support.
"Payee"
refers to an SSI payee as defined in
				  Iowa Code subsections
				  633.33(7)
				   and
				  633.3(20).
"Recertification"
in the medically needy
				  coverage group shall mean establishing a new certification period when the
				  previous period has expired and there has not been a break in
				  assistance.
"Recipient"
shall mean a person who is
				  receiving assistance including receiving assistance for another person.
"Responsible relative"
for medically needy
				  shall mean a spouse, parent, or stepparent living in the household of the
				  client.
"Retroactive certification period"
for
				  medically needy shall mean one, two, or three calendar months prior to the date
				  of application, as provided in 441-subrule 76.13(3). The retroactive
				  certification period begins with the first month Medicaid-covered services were
				  received and continues to the end of the month immediately prior to the month
				  of application.
"Retroactive period"
shall mean the three or
				  fewer calendar months immediately preceding the month in which an application
				  is filed, pursuant to 441-subrule 76.13(3).
"Spenddown"
shall mean the process by which
				  a medically needy person obligates excess income for allowable medical expenses
				  to reduce income to the appropriate MNIL.
"SSI-related"
shall mean those persons whose
				  eligibility is derived from regulations governing the supplemental security
				  income (SSI) program except that income shall be considered
				  prospectively.
"SSI-related medically needy"
shall mean
				  those persons whose eligibility is derived from regulations governing the
				  supplemental security income (SSI) program except for income or
				  resources.
"Supply"
shall mean the requested
				  information is received by the department by the specified due date.
"Transfer of assets"
shall mean transfer of
				  resources or income for less than fair market value for the purposes of rule
				  441-75.23 (249A). For example, a
				  transfer of resources or income could include establishing a trust,
				  contributing to a charity, removing a name from a resource or income, or
				  reducing ownership interest in a resource or income.
"Unborn child"
shall include an unborn child
				  during the entire term of pregnancy.
This rule is intended to implement Iowa Code sections
				  249A.3 and
				  249A.4.