TITLE VIII
MEDICAL ASSISTANCE
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 pursuant to 2013 Iowa Acts, Senate File 446, sections 166 to 173 and 185 to 187. Implementation of the Iowa Health and Wellness Plan is subject to approval by the Secretary of the United States Department of Health and Human Services of any waivers of the requirements of Title XIX of the Social Security Act to provide for federal funding of the plan. 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.
[ARC 1135C, IAB 10/30/13, effective 10/2/13]
441—74.1(249A,85GA,SF446) Definitions.
“Accountable care organization” means a risk-bearing, integrated health care organization characterized by a payment and care delivery model that ties provider reimbursement to quality metrics and reductions in the total cost of care for an attributed population of patients.
“Countable income” means “modified adjusted gross income” (MAGI) or “household income,” as applicable, determined pursuant to 42 U.S.C. § 1396a(e)(14).
“Department” means the Iowa department of human services.
“Enrollment period” means the 12-month period for which eligibility is initially established.
“Essential health benefits” means the essential health benefits defined by the Secretary of the United States Department of Health and Human Services pursuant to Section 1302(b) of the Patient Protection and Affordable Care Act, Public Law 111-148.
“Exempt individuals” shall be defined pursuant to 42 CFR § 440.315.
“Federal poverty level” means the poverty income guidelines revised annually and published in the Federal Register by the U.S. Department of Health and Human Services.
“Health insurance marketplace” or “exchange” means an American health benefit exchange established pursuant to 42 U.S.C. § 18031.
“Iowa Health and Wellness Plan” means the medical assistance program set forth in this chapter.
“Iowa wellness plan” means the benefits and services provided to Iowa Health and Wellness Plan members with countable income that does not exceed 100 percent of the federal poverty level.
“Marketplace choice plan” means the benefits and services provided to Iowa Health and Wellness Plan members with countable income between 101 percent and 133 percent of the federal poverty level.
“Member” means an individual who is receiving assistance under the Iowa Health and Wellness Plan described in this chapter.
“Minimum essential coverage” means health insurance defined in Section 5000A(f) of Subtitle D of the Internal Revenue Code.
“Modified adjusted gross income” means the financial-eligibility methodology prescribed in 42 U.S.C. § 1396a(e)(14).
“Qualified employer-sponsored coverage” shall be defined pursuant to 42 U.S.C. § 1396e-1(b).
“Qualified health plan” shall be defined pursuant to Section 1301 of the Patient Protection and Affordable Care Act, Public Law 111-152.
[ARC 1135C, IAB 10/30/13, effective 10/2/13]
441—74.2(249A,85GA,SF446) 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; and
	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.
	74.2(2) Parents or caretakers of dependent children. All dependent children under the age of 21 living with a parent or other caretaker relative 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 other caretaker relative’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.
[ARC 1135C, IAB 10/30/13, effective 10/2/13]
441—74.3(249A,85GA,SF446) Application. Medicaid application policies and procedures described in 441—Chapter 76 shall apply to applications for the Iowa Health and Wellness Plan.
[ARC 1135C, IAB 10/30/13, effective 10/2/13]
441—74.4(249A,85GA,SF446) 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.
[ARC 1135C, IAB 10/30/13, effective 10/2/13]
441—74.5(249A,85GA,SF446) Enrollment period.
	74.5(1) Iowa Health and Wellness Plan eligibility shall be effective on the first day of the month following 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,85GA,SF446).
	74.5(2) Care provided before enrollment. No payment shall be made for medical care received before the effective date of enrollment.
	74.5(3) Reinstatement. Enrollment for the Iowa Health and Wellness Plan may be reinstated without a new application in accordance with 441—subrule 76.12(2).
[ARC 1135C, IAB 10/30/13, effective 10/2/13]
441—74.6(249A,85GA,SF446) Reporting changes.
	74.6(1) Reporting requirements. 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 or enrolled in Medicare Part A or Part B or both.
	e. 	The member’s dependent child loses minimum essential coverage.
	f. 	The member’s countable income increases in a manner that must be reported according to the requirements of rule 441—76.15(249A).
	g. 	The member is confirmed 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 rule 441—75.28(249A).
	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 7.7(1); or
	b. 	The enrollment period has expired and the member is not eligible for a new enrollment period.
[ARC 1135C, IAB 10/30/13, effective 10/2/13]
441—74.7(249A,85GA,SF446) Reenrollment. A new eligibility determination is required for consecutive 12-month enrollment periods. The reenrollment process will follow the requirements in 441—subrule 76.14(2).
[ARC 1135C, IAB 10/30/13, effective 10/2/13]
441—74.8(249A,85GA,SF446) Terminating enrollment. Iowa Health and Wellness Plan enrollment shall end when any of the following occur:
	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 or enrolled in Medicare Part A or Part B or both.
	8.	The member’s dependent child loses minimum essential coverage.
	9.	The member’s countable income exceeds 133 percent of the federal poverty level.
	10.	The member becomes pregnant.
	11.	The Iowa Health and Wellness Plan is discontinued according to the requirements in rule 441—74.14(249A,85GA,SF446).
[ARC 1135C, IAB 10/30/13, effective 10/2/13]
441—74.9(249A,85GA,SF446) Recovery. The department shall recover from a member all Medicaid funds incorrectly expended on behalf of the member in accordance with rule 441—75.28(249A).
	74.9(1) The department shall recover Medicaid funds expended on behalf of a member from the member’s estate in accordance with rule 441—75.28(249A).
	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 Iowa Medicaid enterprise, and an adjustment shall be made to a previously submitted claim.
[ARC 1135C, IAB 10/30/13, effective 10/2/13]
441—74.10(249A,85GA,SF446) Right to appeal. Decisions and actions by the department regarding eligibility or services provided under this chapter may be appealed pursuant to 441—Chapter 7. Coverage decisions and actions by participating marketplace choice plans shall be appealed through the plans’ grievance and appeal processes. 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,85GA,SF446).
[ARC 1135C, IAB 10/30/13, effective 10/2/13]
441—74.11(249A,85GA,SF446) Financial participation.
	74.11(1) Copayment. Payment for nonemergency use of a hospital emergency department shall be subject to a $10 copayment by the member, which shall be subtracted from the Iowa Health and Wellness Plan payment otherwise due to the provider. This copayment will be waived during the first year of the Iowa Health and Wellness Plan.
	74.11(2) Reserved.
[ARC 1135C, IAB 10/30/13, effective 10/2/13]
441—74.12(249A,85GA,SF446) Benefits and service delivery. Covered benefits and the service delivery method shall be determined by the member’s countable income and health status.
	74.12(1) Iowa wellness plan services. Iowa Health and Wellness Plan members with countable income that does not exceed 100 percent of the federal poverty level shall be enrolled in the Iowa wellness plan unless the member is determined by the department to be an exempt individual. The department shall provide the member with a medical assistance eligibility card identifying the member as eligible for Iowa wellness plan services.
	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), prescription drugs and dental services consistent with 441—Chapter 78, and habilitation services consistent with rule 441—78.27(249A).
	b. 	The Iowa Health and Wellness Plan provider network shall include all providers enrolled in the medical assistance program, including all participating accountable care organizations.
	c. 	Members enrolled in the Iowa wellness plan shall be subject to enrollment in managed care, other than PACE programs, pursuant to 441—Chapter 88. In addition to reimbursement for managed care pursuant to 441—Chapter 88, the department may provide care coordination fees, performance incentive payments, or shared savings arrangements for medical homes and accountable care organizations serving members enrolled in the Iowa Health and Wellness Plan.
	d. 	When the member does not choose a primary medical provider, the department shall assign the member to a primary medical provider in accordance with the Medicaid managed health care mandatory enrollment provisions specified in 441—subrule 88.3(7) for mandatory enrollment counties and in accordance with quality data available to the department.
	74.12(2) Marketplace choice plan services. Iowa Health and Wellness Plan members with countable income between 101 percent and 133 percent of the federal poverty level shall be enrolled in a marketplace choice plan unless the member is determined by the department to be an exempt individual. Marketplace choice coverage shall be provided through designated qualified health plans available on the health insurance marketplace. Covered services not provided by the marketplace choice plan will be provided by the medical assistance program. Individuals who have been determined eligible for the marketplace choice plan, but who have not yet been enrolled in a marketplace choice plan, shall receive fee-for-service coverage under the Iowa wellness plan until they choose or are assigned to a marketplace choice plan.
	a. 	Upon enrollment, a member shall choose a qualified health plan from those designated by the department to provide coverage to Iowa Health and Wellness Plan members.
	b. 	When the member does not select a qualified health plan pursuant to notice of the need to do so, the department will select a plan, enroll the member, and notify the member of the assigned plan.
	c. 	The department shall pay premiums to designated qualified health plans participating on the health insurance marketplace to buy coverage for eligible Iowa Health and Wellness Plan members. The department shall begin payment of the member’s premiums for the first month of enrollment through the Iowa Health and Wellness Plan. The qualified health plan shall provide the member with an insurance card identifying the member as an enrollee of the plan. The department shall provide the member with a medical assistance eligibility card identifying the member as eligible for the marketplace choice plan.
	d. 	Covered services are all benefits, including essential health benefits, provided by the designated qualified health plan on the health insurance marketplace, including prescription drugs. Dental services shall be provided through a contract with a commercial dental plan with covered services consistent with 441—Chapter 78. Services not covered by the qualified health plan, but covered pursuant to the marketplace choice 1115 waiver or the marketplace choice state plan will be covered by the Medicaid program.
	74.12(3) Exempt individuals. An Iowa Health and Wellness Plan member who has been determined by the department to be an 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.
	74.12(4) 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.
[ARC 1135C, IAB 10/30/13, effective 10/2/13]
441—74.13(249A,85GA,SF446) Claims and reimbursement methodologies.
	74.13(1) Claims for services not provided by a qualified health plan. Claims for services provided under the Iowa wellness plan or for covered marketplace choice services not provided by the member’s qualified health plan shall be submitted to the Iowa Medicaid enterprise as required by 441—Chapter 80.
	74.13(2) Payment for services not provided by a qualified health plan. Payment for services provided under the Iowa wellness plan or for covered marketplace choice services not provided by the member’s qualified health plan shall be provided in accordance with 441—Chapter 79 or as provided in a contract between the department and the provider.
	74.13(3) Payment for services provided by the marketplace choice plan. Payment for services provided under the marketplace choice plan shall be made in accordance with the rates filed with the Iowa insurance division.
[ARC 1135C, IAB 10/30/13, effective 10/2/13]
441—74.14(249A,85GA,SF446) 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 Health and 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.
[ARC 1135C, IAB 10/30/13, effective 10/2/13]
441—74.15(249A,85GA,SF446) Enrollment for IowaCare members.
	74.15(1) Subject to a waiver of the eligibility requirements of 42 U.S.C. § 1396a(e)(14)(A) by the federal Centers for Medicare and Medicaid Services, and notwithstanding any other provision of this chapter, an individual who is enrolled in the IowaCare program under 441—Chapter 92 on October 1, 2013, shall be enrolled without an application in the Iowa Health and Wellness Plan effective January 1, 2014, if department records show:
	a. 	That the income of all household members considered in determining the individual’s eligibility for IowaCare (other than child support income) does not exceed 138 percent of the federal poverty level for a household of that size, based on the following sources of income information, in the following order of priority:
	(1)	Income used to determine eligibility for food assistance for the individual and other IowaCare household members, pursuant to 441—Chapter 92;
	(2)	Income used to determine eligibility for medical assistance for other IowaCare household members, pursuant to 441—Chapter 75;
	(3)	Iowa workforce development unemployment insurance benefit data available to the department pursuant to 441—paragraph 9.10(4)“c”;
	(4)	Iowa workforce development wage data available to the department pursuant to 441—paragraph 9.10(4)“c”;
	(5)	Income and eligibility verification system data available to the department pursuant to 441—paragraph 9.10(4)“c”; and
	b. 	That the individual meets all eligibility requirements of the Iowa Health and Wellness Plan, pursuant to this chapter, other than income.
	74.15(2) Individuals enrolled pursuant to this rule will thereafter be subject to all the provisions of this chapter, with no further application of this rule.
[ARC 1214C, IAB 12/11/13, effective 11/13/13]
These rules are intended to implement 2013 Iowa Acts, Senate File 446, sections 166 to 173 and 185 to 187, and Iowa Code chapter 249A.
[Filed Emergency After Notice ARC 1135C (Notice ARC 0972C, IAB 8/21/13), IAB 10/30/13, effective 10/2/13]
[Filed Emergency ARC 1214C, IAB 12/11/13, effective 11/13/13]