ARC 6933C
HUMAN SERVICES DEPARTMENT[441]
Adopted and Filed
Rule making related to Iowa health and wellness plan
The Human Services Department hereby rescinds Chapter 74, “Iowa Health and Wellness Plan,” Iowa Administrative Code, and adopts a new Chapter 74 with the same title.
Legal Authority for Rule Making
This rule making is adopted under the authority provided in Iowa Code sections 249A.4 and 249N.6.
State or Federal Law Implemented
This rule making implements, in whole or in part, Iowa Code sections 249A.4 and 249N.6.
Purpose and Summary
Chapter 74 was reviewed as part of the Department’s five-year rules review. Chapter 74 defines and structures the Iowa health and wellness plan. The chapter is rescinded and replaced to eliminate rules that are outdated, redundant and inconsistent. Terminology is updated in the new chapter. The references to marketplace choice are removed since it no longer exists. Retroactive enrollment has been updated to include residential nursing facilities. The website has been added as a payment method for contributions. Members are no longer be required to pay premiums when no services were provided.
Public Comment and Changes to Rule Making
Notice of Intended Action for this rule making was published in the Iowa Administrative Bulletin on December 28, 2022, as ARC 6765C. No public comments were received. No changes from the Notice have been made.
Adoption of Rule Making
This rule making was adopted by the Council on Human Services on February 9, 2023.
Fiscal Impact
This rule making has no fiscal impact to the State of Iowa.
Jobs Impact
After analysis and review of this rule making, no impact on jobs has been found.
Waivers
Any person who believes that the application of the discretionary provisions of this rule making would result in hardship or injustice to that person may petition the Department for a waiver of the discretionary provisions, if any, pursuant to rule 441—1.8(17A,217).
Review by Administrative Rules Review Committee
The Administrative Rules Review Committee, a bipartisan legislative committee which oversees rule making by executive branch agencies, may, on its own motion or on written request by any individual or group, review this rule making at its regular monthly meeting or at a special meeting. The Committee’s meetings are open to the public, and interested persons may be heard as provided in Iowa Code section 17A.8(6).
Effective Date
This rule making will become effective on May 1, 2023.
The following rule-making action is adopted:
	Rescind 441—Chapter 74 and adopt the following new chapter in lieu thereof:
CHAPTER 74
IOWA HEALTH AND WELLNESS PLAN
preamble
This chapter defines and structures the Iowa health and wellness plan, effective January 1, 2014, and administered by the department of human services (department) pursuant to Iowa Code chapters 249A and 249N. This chapter shall be construed to comply with all requirements for federal funding under Title XIX of the Social Security Act or under the terms of any applicable waiver granted by the Secretary. To the extent this chapter is inconsistent with any applicable federal funding requirement under Title XIX or the terms of any applicable waiver, the requirements of Title XIX or the terms of the waiver shall prevail.
441—74.1(249A,249N) Definitions. 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).
441—74.2(249A,249N) Eligibility factors. 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.
	74.2(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.
	74.2(2) Parents or caretakers of dependent children. All children under the age of 21 living with a parent or caretaker who will be claimed as a dependent by the parent or caretaker for state or federal income tax purposes must be enrolled in Medicaid, in the Children’s Health Insurance Program (CHIP), or in other minimum essential coverage as a condition of the parent’s or caretaker’s eligibility for Iowa health and wellness plan benefits.
	74.2(3) Citizenship. To be eligible for Iowa health and wellness plan benefits, a person must meet the citizenship requirements in 441—Chapter 75.
441—74.3(249A,249N) Application. Medicaid application policies and procedures described in 441—Chapter 76 shall apply to applications for the Iowa health and wellness plan.
441—74.4(249A,249N) Financial eligibility.
	74.4(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.
	74.4(2) Household size. For financial eligibility purposes, household size shall be determined according to the modified adjusted gross income (MAGI) methodology.
441—74.5(249A,249N) Enrollment period.
	74.5(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).
	74.5(2) Reinstatement. Enrollment for the Iowa health and wellness plan may be reinstated without a new application in accordance with 441—Chapter 76.
	74.5(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.
	74.5(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.
441—74.6(249A,249N) Reporting changes.
	74.6(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.
	74.6(2) Untimely report. When a change is not timely reported as required by this rule, any program expenditures for care or services provided when the member was not eligible shall be considered an overpayment and be subject to recovery from the member in accordance with 441—Chapters 75 and 11. Program expenditures may include, but are not limited to, premiums and capitation payments.
	74.6(3) Effective date of change. After enrollment, changes reported during the month that affect the member’s eligibility shall be effective the first day of the next calendar month unless:
	a. 	Timely notice of adverse action is required as specified in 441—subrule 16.3(1); or
	b. 	The enrollment period has expired and the member is not eligible for a new enrollment period.
441—74.7(249A,249N) Reenrollment. A new eligibility determination is required for consecutive 12-month enrollment periods. The reenrollment process will follow the requirements in 441—Chapter 76.
441—74.8(249A,249N) Terminating enrollment. 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).
441—74.9(249A,249N) Recovery. The department shall recover from a member all Medicaid funds incorrectly expended on behalf of the member in accordance with 441—Chapter 75.
	74.9(1) The department shall recover Medicaid funds expended on behalf of a member from the member’s estate in accordance with 441—Chapter 75.
	74.9(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.
441—74.10(249A,249N) Right to appeal.
	74.10(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.
	74.10(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).
441—74.11(249A) Financial participation.
	74.11(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.
	74.11(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.
	b. 	Waiver during the first year of enrollment. The monthly contribution will be waived during the member’s first 12 months of continuous enrollment.
	c. 	Monthly contribution exemptions. A member shall be exempt from monthly contribution payments when any of the following circumstances apply:
	(1)	The member completed healthy behaviors pursuant to subrule 74.11(4) in the previous enrollment period.
	(2)	The member is determined by the department to be a medically exempt individual pursuant to subrule 74.12(2).
	(3)	The member has access to cost-effective, employer-sponsored coverage and is enrolled in the health insurance premium payment program pursuant to 441—Chapter 75.
	(4)	The member is exempt from premiums pursuant to 42 CFR 447.56(a)(1)(x) as amended to May 16, 2022, as an Indian who is eligible to receive or has received an item or service furnished by an Indian health care provider or through referral under contract health services.
	(5)	The member claims a hardship exemption indicating that payment of the monthly contribution will be a financial hardship. The member may claim a hardship exemption by telephoning the call center designated by the department, by checking the hardship box on the billing statement (for the month of the billing statement), or by submitting a written statement to the address designated by the department. The member’s hardship exemption must be received or postmarked within five working days after the monthly contribution due date. If the hardship exemption request is not made in a timely manner, the exemption shall not be granted.
	d. 	Billing and payment. Form 470-5285 or 470-5285(S) shall be used for billing and collection of the monthly contribution.
	(1)	Method of payment. Members shall submit contribution payments to the following address: Iowa Medicaid, Iowa Health and Wellness Plan Monthly Contributions, P.O. Box 14485, Des Moines, Iowa 50306-3485. Members can also submit contributions through the department’s website.
	(2)	Due date. When the department notifies a member of the amount of the monthly contribution, the member shall pay any monthly contributions due in accordance with the following:
	1.	The monthly contribution for each month is due on the last calendar day of the month that the monthly contribution is to cover.
	2.	If the last calendar day falls on a weekend or state or federal holiday, payment is due on the first working day following the weekend or holiday.
	3.	Monthly contribution payments must be received or postmarked by the due date.
	(3)	Application of payment. The department shall apply monthly contributions payments received to the oldest unpaid month in the current enrollment period. When monthly contributions for all months in the enrollment period have been paid, the department shall hold any excess and apply it to any months for which eligibility is subsequently established.
	e. 	Failure to pay monthly contributions.
	(1)	An Iowa health and wellness plan member with household income between 50 and 100 percent of the FPL who fails to pay the assessed monthly contributions and who does not qualify for a monthly contribution exemption pursuant to subrule 74.11(2) shall owe the monthly contribution to the department as an unpaid premium subject to recovery in accordance with 441—Chapter 75. A member shall have no less than 90 days from the due date to pay any unpaid monthly contribution before the unpaid amount shall be subject to recovery.
	(2)	An Iowa health and wellness plan member with household income above 100 percent of the FPL who fails to pay the assessed monthly contribution and who does not qualify for a monthly contribution exemption pursuant to subrule 74.11(2) shall have the member’s eligibility terminated. In addition, the member shall owe the monthly contribution to the department as an unpaid premium subject to recovery in accordance with 441—Chapter 75. A member shall have no less than 90 days from the due date to pay any unpaid monthly contribution before the unpaid amount shall be subject to recovery.
	1.	A member shall have no less than 90 days from the due date to pay any unpaid monthly contribution before eligibility will be terminated or the unpaid amount will be subject to recovery.
	2.	A member whose eligibility is terminated due to nonpayment of monthly contributions may reenroll for Medicaid benefits pursuant to 441—Chapter 76.
	3.	Unpaid premiums shall not be considered a collectible debt by the state if, at the member’s next annual renewal date, the member does not apply for renewed eligibility, and the member has no claims for services delivered after the month of the last premium payment.
	f. 	Refund of monthly contributions.
	(1)	Monthly contributions paid for any period shall be refunded if the member qualified for a monthly contribution exemption pursuant to paragraph 74.11(2)“c” or when a member’s Iowa health and wellness plan coverage is terminated for the following reasons:
	1.	The member is no longer eligible for coverage in the Iowa health and wellness plan; or
	2.	The member dies.
	(2)	The amount of any refund shall be offset by any outstanding monthly contributions owed.
	(3)	The refund shall be paid within two calendar months from the date of termination from the program.
	74.11(3) Aggregate annual limits on copayments and monthly contributions. The total aggregate annual amount of copayments and monthly contributions for an individual shall not exceed 5 percent of the household’s countable annual income determined pursuant to 441—Chapter 75.
	74.11(4) Healthy behaviors. An Iowa health and wellness plan member who completes a wellness examination and health risk assessment during any enrollment year shall have monthly contributions waived in the subsequent enrollment year.
	a. 	Under healthy behaviors, a wellness examination may be related to either physical health or oral health. Physical examinations must be performed by a medical provider and must assess a member’s overall physical health consistent with standard clinical guidelines for preventive physical examinations and as defined by the department. Oral examinations must be performed by a dental provider consistent with standard oral health guidelines for preventive dental examinations and as defined by the department.
	b. 	A health risk assessment is an assessment offered by a managed care plan through which the member is receiving Iowa health and wellness plan benefits.
441—74.12(249A) Benefits and service delivery. Covered benefits and the service delivery method shall be determined by the member’s health status.
	74.12(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.
	74.12(2) Medically exempt individuals. An Iowa health and wellness plan member who has been determined by the department to be a medically exempt individual shall be given the choice of the benefits and service delivery method provided by the Iowa wellness plan or receiving benefits and services pursuant to 441—Chapter 78.
	a. 	A member may attest to being a medically exempt individual by submitting a completed Form 470-5194.
	b. 	A provider with a current national provider identifier number, an employee of the department, a designee of the department of corrections, a managed care organization, or a mental health and disability services region established pursuant to Iowa Code sections 331.388 to 331.399 may refer a member for a medically exempt individual determination by submitting a completed Form 470-5198.
	c. 	Upon receipt of Form 470-5194 or 470-5198, the department shall determine whether the member qualifies as a medically exempt individual in accordance with 42 CFR 440.315 as amended to May 16, 2022.
	74.12(3) Qualified employer-sponsored coverage. An individual who has access to cost-effective, employer-sponsored coverage shall be subject to enrollment in the health insurance premium payment program pursuant to 441—Chapter 75.
441—74.13(249A,249N) Claims and reimbursement methodologies. 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.
441—74.14(249A,249N) Discontinuance of program.
	74.14(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.
	74.14(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.
These rules are intended to implement Iowa Code chapters 249A and 249N.
[Filed 2/14/23, effective 5/1/23]
[Published 3/8/23]
Editor’s Note: For replacement pages for IAC, see IAC Supplement 3/8/23.