CHAPTER 92
IOWACARE
Preamble
This chapter defines and structures the IowaCare program administered by the department pursuant to Iowa Code Supplement chapter 249J. It is the department’s intent that all state expenditures under the IowaCare program shall qualify for federal financial participation under Title XIX of the Social Security Act (Medical Assistance or Medicaid), as allowed by waivers of Title XIX requirements granted by the Secretary of the U.S. Department of Health and Human Services pursuant to Section 1115 of the Social Security Act (42 U.S.C. §1315). Therefore, this chapter shall remain in effect only as long as such waivers are effective. Further, this chapter shall be construed to comply with the requirements of Title XIX or with the terms of any applicable waiver of Title XIX requirements. To the extent that these rules may be found to be inconsistent with any applicable requirement of Title XIX or the terms of any applicable waiver, the requirements of Title XIX or the terms of the waiver shall prevail.
441—92.1(249A,249J) Definitions.
“Applicant” means an individual who applies for medical assistance under the IowaCare program described in this chapter.
“Clean claim” means a claim that can be adjudicated in the Medicaid claims payment system to result in either a paid or denied status.
“Department” means the Iowa department of human services.
“Dependent child” means the child or stepchild of an applicant or member who is living in the applicant’s or member’s home and is under the age of 18 or is 18 years of age and will graduate from high school or an equivalent level of vocational or technical school or training leading to a certificate or diploma before reaching the age of 19. Correspondence school is not an allowable program of study. “Dependent child” shall also include a child attending college or a school of higher learning beyond high school if the parents will claim the child as a dependent on their state or federal income tax return.
“Enrollment period” means the entire period that a member receives IowaCare without a break, which may include multiple certification periods.
“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.
“Group health insurance” means any plan of or contributed by an employer (including a self-insured plan) to provide health care (directly or otherwise) to the employer’s employees, former employees, or the families of the employees or former employees.
“Indian” means a Native American eligible, as an Indian, to receive health care services from an Indian health care provider as defined in this rule.
“Indian health care provider” means a health care program operated by the Indian Health Service of the U.S. Department of Health and Human Services or by an Indian tribe, tribal organization, or urban Indian organization as those terms are defined in 25 U.S.C. § 1603.
“Initial application” means the first application for IowaCare or an application that is filed after a break in assistance of one month or more.
“IowaCare” means the medical assistance program explained in this chapter.
“Medical expansion services” means the services described in Iowa Code section 249J.6.
“Medical home” means a team approach to providing health care that originates in a primary care setting; fosters a partnership among the patient, the personal provider, other health care professionals, and where appropriate, the patient’s family; utilizes the partnership to access all medical and nonmedical health-related services needed by the patient and the patient’s family to achieve maximum health potential; maintains a centralized, comprehensive record of all health-related services to promote continuity of care; and has all of the characteristics specified in Iowa Code section 135.158.
“Member” means an individual who is receiving assistance under the IowaCare program described in this chapter.
“Newborn” means an infant born to a woman as defined in paragraph 92.2(1)“b.”
“Nonparticipating provider” means a hospital that is located in Iowa and licensed pursuant to Iowa Code chapter 135B but that is not an IowaCare provider pursuant to subrule 92.8(1).
“Provider-directed care coordination services” means provider-directed services in a clinical setting aimed at managing all aspects of a patient’s care to ensure quality of care and safety. All aspects of care are coordinated by the clinical team under the direction of a physician. The team must include a dedicated care coordinator.
[ARC 9135B, IAB 10/6/10, effective 10/1/10; ARC 0760C, IAB 5/29/13, effective 5/8/13]
441—92.2(249A,249J) Eligibility. IowaCare eligibility shall be determined according to the requirements of rules 441—75.2(249A) to 441—75.4(249A), 441—75.7(249A), 441—75.10(249A), and 441—75.12(249A) and the provisions of this rule.
	92.2(1) Persons covered. Medical assistance under IowaCare shall be available to the following people as provided in this chapter:
	a. 	Persons 19 through 64 years of age who:
	(1)	Are not eligible for medical assistance under 441—subrules 75.1(1) through 75.1(40) or 75.1(42), including persons unable to meet spenddown under 441—subrule 75.1(35); and
	(2)	Have countable income at or below 200 percent of the federal poverty level.
	b. 	Pregnant women whose:
	(1)	Gross countable income is below 300 percent of the federal poverty level; and
	(2)	Allowable medical expenses reduce their countable income to 200 percent of the federal poverty level or below.
	c. 	Newborn children born to women defined in paragraph “b.”
	92.2(2) Citizenship. To be eligible for IowaCare benefits, a person must meet the requirements in 441—subrule 75.11(2). A person who claims a qualified alien status shall provide documentation of this status.
	92.2(3) Other disqualification. A person who has been disqualified from Medicaid for reasons other than excess income, excess resources, or lack of categorical eligibility is not eligible for IowaCare benefits.
	92.2(4) Group health insurance. A person who has access to group health insurance is not eligible for IowaCare. The department shall use Form 470-4542, IowaCare Insurance Information Request, to obtain information to confirm the status of an IowaCare member’s group health insurance. An applicant or member shall not be considered to have access to group health insurance if any of the following conditions exist:
	a. 	The applicant or member is not enrolled in the available group health plan and states that:
	(1)	The coverage is unaffordable; or
	(2)	Exclusions for preexisting conditions apply; or
	(3)	The needed services are not services covered by the plan.
	b. 	The applicant or member is enrolled in a group health plan but states that:
	(1)	Exclusions for preexisting conditions apply; or
	(2)	The needed services are not covered by the plan; or
	(3)	The limits of benefits under the plan have been reached; or
	(4)	The plan includes only catastrophic health care coverage.
	92.2(5) Payment of assessed premiums. IowaCare will be canceled if premiums are not paid in accordance with 441—92.7(249A,249J). However, an application for IowaCare shall not be affected by any unpaid premiums from any previous certification period.
	92.2(6) Availability of funds. Eligibility for IowaCare shall not be approved when the department has determined that there are insufficient funds available to pay for additional enrollment, in accordance with 441—92.14(249A,249J).
[ARC 8505B, IAB 2/10/10, effective 4/1/10; ARC 9135B, IAB 10/6/10, effective 10/1/10]
441—92.3(249A,249J) Application. Medicaid application policies in 441—76.1(249A) and 441—76.8(249A) apply to IowaCare except as follows:
	92.3(1) An application for IowaCare may also be submitted on Comm. 239, IowaCare Application, or Form 470-4364, IowaCare Renewal Application. An applicant who submits an application on another form allowed under 441—76.1(249A) and has income over 150 percent of the federal poverty level shall also sign Form 470-4194, IowaCare Premium Agreement, and submit it within ten days of the department’s request.
	92.3(2) A new application is required for each certification period.
[ARC 9135B, IAB 10/6/10, effective 10/1/10; ARC 9982B, IAB 2/8/12, effective 4/1/12]
441—92.4(249A,249J) Application processing. Department staff shall process IowaCare applications. The department shall base eligibility decisions primarily on information declared by the applicant. A face-to-face interview is not required.
	92.4(1) Verification. Applicants seeking eligibility under 92.2(1)“b” shall provide verification of medical expenses as required under 92.5(5)“b.” IowaCare applicants shall not be required to provide verification of income, household members, disability, social security number, age, HAWK-I premium, group health insurance, or pregnancy, unless the verification is specifically requested in writing.
	a. 	The department shall notify the person in writing of any further verification requested. The person shall have five working days to supply the requested information. The local office may extend the deadline for a reasonable period when the person is making every effort but is unable to secure the required information or verification from a third party.
	b. 	Failure of the person to supply requested information or refusal by the person to authorize the department to secure the information from other sources shall serve as a basis for denial of an application or cancellation of IowaCare benefits.
	c. 	If benefits are denied or canceled for failure to provide information and the information is provided within 14 calendar days of the effective date of the denial or cancellation, the department shall complete the eligibility determination as though the information were received timely. If the fourteenth calendar day falls on a weekend or state holiday, the client shall have until the next business day to provide the information.
	92.4(2) Screening for full Medicaid. The department shall screen each application for eligibility under coverage groups listed in 441—75.1(249A). If the applicant is eligible under another coverage group, the IowaCare application shall be considered an application for that coverage group.
	92.4(3) Time limit for decision. The department shall make a determination of approval or denial as soon as possible, but no later than three working days after the filing date of the application, unless:
	a. 	One or more conditions listed in 441—subrule 76.3(1), 76.3(3), 76.3(4), or 76.3(6) exist; or
	b. 	The application is being processed for Medicaid eligibility under a coverage group listed in 441—75.1(249A).
[ARC 8500B, IAB 2/10/10, effective 3/1/10]
441—92.5(249A,249J) Determining income eligibility. The department shall determine the income of an applicant’s household as of the date of decision. To be eligible, the household’s income minus allowable deductions shall not exceed 200 percent of the federal poverty level for the household size.
	92.5(1) Household size. The household size shall include the applicant and the applicant’s dependent or unborn children and spouse living in the same home, except when a dependent child or spouse has elected to receive supplemental security income under Title XVI of the Social Security Act. A person who is absent from the home shall not be included in the household size, unless the absence is temporary.
	a. 	An applicant’s spouse shall not be considered absent from the home when:
	(1)	The spouse’s absence is due solely to a pattern of employment, including active duty in the uniformed services of the United States.
	(2)	The spouse is a convicted offender but is permitted to live at home while serving a court-imposed sentence by performing unpaid public work or unpaid community service during the workday.
	b. 	The conditions described in 441—paragraph 75.53(4)“b” shall be applied to determine whether a person’s absence is temporary.
	92.5(2) Self-declaration of income. Applicants shall self-declare the household’s future unearned and earned income based on their best estimate.
	a. 	Applicants who receive income on a regular basis shall declare their household’s monthly income as described at 92.5(3) and 92.5(4).
	b. 	Applicants who are self-employed, receive their income on an irregular basis, or are not currently employed shall declare their household’s anticipated yearly income as described in 92.5(3) and 92.5(4).
	92.5(3) Earned income. All earned income as defined in this subrule that is received by a person included in the household size shall be counted except for the earnings of a child who is a full-time student as defined in 441—subparagraphs 75.54(1)“b”(1), (2), and (3). Earned income shall include income in the form of a salary, wages, tips, or profit from self-employment.
	a. 	For income from salary, wages, or tips, earned income shall mean the total gross amount of income irrespective of the expenses of employment.
	b. 	For self-employment income, earned income shall mean the net profit from self-employment, defined as gross income less the costs of producing the income.
	c. 	Gross income from providing child care in the applicant’s or member’s own home shall include the total payments received for the service and any payment received due to the Child Nutrition Amendments of 1978 for the cost of providing meals to children.
	(1)	In determining the net profit counted as earned income from providing child care services in the applicant’s or member’s own home, 40 percent of the total gross income received shall be deducted to cover the costs of producing the income, unless the applicant or member requests to have actual expenses in excess of the 40 percent considered.
	(2)	When the applicant or member verifies expenses in excess of 40 percent of the total gross income received, the net profit counted as earned income shall be determined in the same manner as specified at paragraph 92.5(3)“b.”
	92.5(4) Unearned income. Unearned income of all household members shall be counted unless exempted as income by:
	a. 	441—subrule 75.57(6), paragraph “b,” “c,” “d,” “e,” “f,” “g,” “h,” “i,” “j,” “k,” “l,” “m,” “p,” “q,” “r,” “t,” “u,” “v,” “w,” “x,” “y,” “z,” or “aa”; or
	b. 	441—subrule 75.57(7), paragraph “a,” “b,” “c,” “d,” “e,” “f,” “g,” “h,” “i,” “j,” “k,” “l,” “m,” or “q.”
	92.5(5) Deductions. The department shall determine a household’s countable income by deducting the following from the household’s self-declared income:
	a. 	Twenty percent of the household’s self-declared earned income.
	b. 	For women applying under 92.2(1)“b,” medical expenses incurred for a person included in the household size that are unpaid and not subject to payment by a third party. Verification of the unpaid expenses must be provided in order to receive the deduction. The medical expenses that can be deducted are:
	(1)	Health insurance premiums, deductibles, or coinsurance charges; and
	(2)	Medical and dental expenses.
	92.5(6) Disregard of changes. A person found to be income-eligible upon application or recertification of eligibility shall remain income-eligible for 12 months regardless of any change in income or household size.
	92.5(7) Unearned nonrecurring lump-sum income. All unearned nonrecurring lump-sum income shall be disregarded.
	92.5(8) Earned lump-sum income. Anticipated earned lump-sum income shall be prorated over the period for which the income is received.
441—92.6(249A,249J) Effective date. The department shall issue Form 470-4164, IowaCare Medical Card, to persons enrolled in the IowaCare program.
	92.6(1) Certification period. IowaCare 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 certification period shall continue for 12 consecutive months. Exceptions:
	a. 	For women and newborns eligible under 92.2(1)“b” or “c,” the certification period shall continue until 60 days after the birth of the child.
	b. 	Certification periods may be adjusted if two or more IowaCare members who were in two households are combined into one household for premium purposes.
	92.6(2) Retroactive eligibility. IowaCare benefits shall also be available for the month preceding the month in which the application is filed if during that preceding month:
	a. 	The applicant received Medicaid expansion services from a provider within the Medicaid expansion network; and
	b. 	The applicant would have been eligible for IowaCare if application had been made.
	92.6(3) Care provided before eligibility. No payment shall be made for medical care received before the effective date of eligibility.
	92.6(4) Reinstatement. Eligibility for IowaCare may be reinstated without a new application when all information necessary to establish eligibility, including verification of any changes, is provided within 14 calendar days of the effective date of the cancellation. If the fourteenth calendar day falls on a weekend or state holiday, the client shall have until the next business day to provide the information. When eligibility can be reestablished, assistance shall be reinstated with an effective date of the first day of the month following the month of cancellation.
[ARC 8500B, IAB 2/10/10, effective 3/1/10; ARC 9135B, IAB 10/6/10, effective 10/1/10]
441—92.7(249A,249J) Financial participation. In addition to the copayments required by 441—subrule 79.1(13), IowaCare members, with the exception of newborns eligible pursuant to 92.2(1)“c” and members in households that include a considered person who pays a Medicaid premium, shall be assessed a sliding-scale monthly premium. A member shall be responsible for paying the premium for the first month after the month of decision and for the following three months, regardless of continued enrollment during the four-month period or during previous months, and for each month of continued enrollment after the required four months. If there is a break in enrollment of one month or more, a new four-month period of mandatory premiums shall be assessed, beginning with the month following the month of decision.
	92.7(1) Premium amount. The monthly premium amount shall be established for the certification period determined pursuant to subrule 92.6(1) beginning with the first month of eligibility, based on projected monthly income for 12 months. On an initial application, no premium shall be assessed for months of eligibility before and including the month of decision, including the retroactive month.
	a. 	The monthly premium is based on the household’s countable monthly income as a percentage of the federal poverty level for a household of that size. If there is more than one IowaCare member in a household, a single premium is established for coverage of all of the members in the household. Subject to the annual update pursuant to paragraph 92.7(1)“b,” for certification periods beginning on or after April 1, 2013, premiums are as follows:

When there is one IowaCare member in the household and the household’s income is at or below:	The member’s premium
amount is:	
150% of federal poverty level	$0	
160% of federal poverty level	$52	
170% of federal poverty level	$56	
180% of federal poverty level	$59	
190% of federal poverty level	$62	
200% of federal poverty level	$66	

When there are two or more IowaCare members in the household and the household’s income is at or below:	The household’s premium
amount is:	
150% of federal poverty level	$0	
160% of federal poverty level	$70	
170% of federal poverty level	$74	
180% of federal poverty level	$79	
190% of federal poverty level	$83	
200% of federal poverty level	$87	
	b. 	The listed premium amount is calculated based on the lowest income level in each 10 percent increment of the federal poverty level for a household of one if there is one IowaCare member in the household or of the federal poverty level for a household of two if there are two or more IowaCare members in the household.
	(1)	Households with income at or below 150 percent of the poverty level are not subject to a premium.
	(2)	Premiums for households with income over 150 percent of the poverty level are 3.5 percent of the lowest applicable income level. The department will update these amounts effective the second month after the month federal poverty level guidelines are released.
	c. 	The cost of HAWK-I premiums paid for household members shall be deducted from the premium assessed according to this subrule.
	d. 	The monthly premium established for a certification period shall not be increased due to an increase in household income or a change in household size.
	e. 	The premium may be reduced prospectively during the certification period if a member declares a reduction in projected average monthly household income or an increase in household size or is granted a hardship exemption.
	92.7(2) Billing and payment. Form 470-4165, IowaCare Billing Statement, shall be used for billing and collection.
	a. 	Method of payment. Members shall submit premium payments to the following address: Iowa Medicaid Enterprise, IowaCare Premiums, P.O. Box 10391, Des Moines, Iowa 50306-9013.
	b. 	Due date. When the department notifies a member of the amount of the premium, the member or household shall pay any premiums due as follows:
	(1)	The premium for each month is due the last calendar day of the month the premium is to cover. Exception: The premiums for the months covered in the initial billing are due the last calendar day of the following month.
	(2)	If the last calendar day falls on a weekend or a state or federal holiday, payment is due the first working day following the holiday or weekend.
	c. 	Application of payment. The department shall apply premium payments received to the oldest unpaid month in the current certification period. When premiums for all months in the certification period have been paid, the department shall hold any excess and apply it to any months for which eligibility is subsequently established.
	92.7(3) Hardship exemption. A member or household that submits a written statement indicating that payment of the monthly premium will be a financial hardship shall be exempted from premium payment for that month, except as provided in paragraph “c.”
	a. 	If the statement is not received by five working days after the premium due date, the member or household shall be obligated to pay the premium.
	b. 	If the statement is timely submitted with a partial payment, exemption shall be granted for the balance owed for that month.
	c. 	A member or household shall not be exempted from premium payment for a month in which the member misrepresented the household’s circumstances.
	92.7(4) Failure to pay premium. If the member or household fails to pay the assessed premium or to declare a hardship by the date the premium is due, the department shall cancel IowaCare benefits effective 60 days after the due date and shall refer the unpaid premiums for collection. A member whose IowaCare benefits are canceled due to nonpayment of premiums must reapply to establish IowaCare eligibility.
	92.7(5) Refund of premium. When a member’s IowaCare coverage is canceled due to a circumstance listed in paragraph “a,” premiums paid for any period after the cancellation date shall be refunded, except to the extent that premiums are still due for any household members whose IowaCare coverage is not canceled.
	a. 	Premiums may be refunded when a member’s IowaCare coverage is canceled because the member:
	(1)	Is determined eligible for medical assistance under 441—subrules 75.1(1) through 75.1(40);
	(2)	Has access to group health insurance coverage as defined in subrule 92.2(4);
	(3)	Reaches age 65;
	(4)	Dies; or
	(5)	No longer meets program requirements after the four mandatory premium months.
	b. 	The amount of the refund shall be offset by any outstanding premiums owed.
	c. 	Any excess premium received for a person who is not receiving IowaCare benefits shall be refunded:
	(1)	Two calendar months after eligibility ended unless an application or reapplication is pending, or
	(2)	Upon the person’s request.
	d. 	Any excess premium received for an IowaCare member shall be refunded:
	(1)	After two calendar months of a zero premium, or
	(2)	Upon the member’s request.
[ARC 7667B, IAB 4/8/09, effective 4/1/09; ARC 9135B, IAB 10/6/10, effective 10/1/10; ARC 9532B, IAB 6/1/11, effective 7/6/11; ARC 9982B, IAB 2/8/12, effective 4/1/12; ARC 0151C, IAB 6/13/12, effective 7/18/12; ARC 0759C, IAB 5/29/13, effective 5/8/13]
441—92.8(249A,249J) Benefits. Under IowaCare, payment will be made only for services and providers as specified in this rule. No payment will be made for any service provided elsewhere or by another provider.
	92.8(1) Provider network. Except as provided in subrules 92.8(3) through 92.8(5), IowaCare members shall have medical assistance only for services provided to the member by:
	a. 	The University of Iowa Hospitals and Clinics; or
	b. 	Broadlawns Medical Center in Des Moines; or
	c. 	A federally qualified health center that the department has designated as part of the IowaCare network using a phased-in approach based on the degree to which the area is underserved, medical home readiness, and the availability of funds; or
	d. 	Any physician, advanced registered nurse practitioner, or physician assistant who is part of a medical institution listed in this subrule. Physician assistants are able to render covered services as auxiliary personnel of a physician pursuant to 441—subrule 78.1(13); or
	e. 	An Indian health care provider enrolled in the IowaCare program, for services provided to Indians.
	92.8(2) Covered services. Services shall be limited to the services covered by the Iowa Medicaid program pursuant to 441—Chapter 78 or 441—79.9(249A) and to medical home services required by subrule 92.8(7). All conditions of service provision shall apply in the same manner as under the regular Iowa Medicaid program and pursuant to 441—Chapter 78, 441—79.3(249A), 441—79.5(249A), 441—79.6(249A), 441—79.8(249A) through 441—79.14(249A), and applicable provider manuals. These conditions include, but are not limited to, prior authorization requirements and exclusions for cosmetic procedures or those otherwise determined not to be required to meet the medical need of the patient.
	92.8(3) Obstetric and newborn coverage. IowaCare members who qualify under 92.2(1)“b” or “c” are also eligible for the services specified in paragraph “a” or “b” from the providers specified in paragraph “c” or “d.”
	a. 	Covered services for pregnant women shall be limited to:
	(1)	Inpatient hospital services when the diagnosis-related group (DRG) submitted for payment is between 370 and 384 and the primary or secondary diagnosis code is V22 through V24.9.
	(2)	Obstetrical services provided in an outpatient hospital setting when the primary or secondary diagnosis code is V22 through V24.9.
	(3)	Services from another provider participating in Medicaid if the claim form reflects that the primary or secondary diagnosis code is V22 through V24.9.
	b. 	Newborns will be eligible while hospitalized and for a period not to exceed 60 days from the date of birth.
	(1)	Inpatient hospital services shall be payable when the diagnosis-related group (DRG) submitted for payment is between 385 and 391.7.
	(2)	Services provided by a health care provider other than a hospital shall be covered as provided in subrule 92.8(2).
	c. 	For persons who reside in Cedar, Clinton, Iowa, Johnson, Keokuk, Louisa, Muscatine, Scott, or Washington County, the services listed in this subrule are covered only when provided by the University of Iowa Hospitals and Clinics or when provided by an Indian health care provider to an Indian.
	d. 	Persons who do not live in Cedar, Clinton, Iowa, Johnson, Keokuk, Louisa, Muscatine, Scott, or Washington County may obtain the services listed in this subrule from any provider that participates in Iowa Medicaid.
	92.8(4) Routine preventive medical examinations. A routine preventive medical examination is one that is performed without relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury.
	a. 	IowaCare members who qualify under paragraph 92.2(1)“b” or “c” and who have not been enrolled with a medical home are eligible to receive routine preventive medical examinations from:
	(1)	Any provider specified under subrule 92.8(1), or
	(2)	Any physician, advanced registered nurse practitioner, or physician assistant who participates in Iowa Medicaid, including but not limited to providers available through a free clinic, a rural health clinic, or a federally qualified health center that has not been designated as an IowaCare provider pursuant to paragraph 92.8(1)“c.” Physician assistants are able to render covered services as auxiliary personnel of a physician pursuant to 441—subrule 78.1(13).
	b. 	A provider that bills IowaCare for a routine preventive medical examination shall use diagnosis code V70 and evaluation and management CPT code 99202, 99203, 99204, 99212, 99213, or 99214, as appropriate to the level of service provided. Basic laboratory work may also be billed in association with the medical examination, as appropriate and necessary.
	92.8(5) Drugs for smoking cessation. IowaCare members may obtain outpatient prescription drugs for smoking cessation that are related to another appropriately billed IowaCare service from any pharmacy participating in the Iowa Medicaid program.
	92.8(6) Medical home. As a condition of participation in the IowaCare program, network providers designated pursuant to subrule 92.8(1) other than Indian health care providers must also qualify as medical homes, pursuant to Iowa Code chapter 135, division XXII.
	a. 	The provider shall meet medical home standards. If the Iowa department of public health adopts rules that provide statewide medical home standards or provide for a statewide medical home certification process, those rules shall apply to IowaCare medical home providers and shall take precedence over the requirements in this paragraph. At a minimum, medical homes shall:
	(1)	Have National Committee for Quality Assurance (NCQA) Level 1 certification or equivalent certification. Effective July 1, 2011, medical homes that achieve a higher level of accreditation from NCQA or equivalent shall be designated as such for purposes of payment.
	(2)	Provide provider-directed care coordination services.
	(3)	Provide members with access to health care and information.
	(4)	Provide wellness and disease prevention services.
	(5)	Create and maintain chronic disease information in a searchable disease registry.
	(6)	Demonstrate evidence of implementation of an electronic health record system.
	(7)	Participate in and report on quality improvement processes.
	b. 	The provider shall execute a contract with the department to be an IowaCare medical home and receive enhanced medical home reimbursements pursuant to subrule 92.9(4). The contract shall include performance measurements and specify expectations and standards for a medical home.
	c. 	If an IowaCare member resides in a designated county near a designated medical home provider, the department shall assign the member to that provider. If an IowaCare member who is assigned to a medical home and who is not an Indian chooses to go to another provider without a referral from the medical home:
	(1)	The service is not covered by the IowaCare program, and
	(2)	The provider may bill the member according to the provider’s established criteria for billing other patients.
	d. 	Subject to subrule 92.8(1), services provided to Indians assigned to a medical home may be covered by the IowaCare program if:
	(1)	Provided by the assigned medical home or pursuant to a referral by the assigned medical home; or
	(2)	Provided by an Indian health care provider enrolled in the IowaCare program or pursuant to a referral by an Indian health care provider enrolled in the IowaCare program.
	92.8(7) Services from nonparticipating providers.
	a. 	A nonparticipating provider hospital may be reimbursed for covered IowaCare services subject to the following conditions and limitations:
	(1)	The patient is enrolled in IowaCare pursuant to the Iowa Medicaid enterprise eligibility verification system at the time the services are delivered.
	(2)	The services are emergency services, as designated by the department, and it is not medically possible to postpone provision of those services.
	(3)	It is not medically possible to transfer the member to an IowaCare provider, or the IowaCare provider does not have sufficient capacity to accept the member.
	(4)	The provision of emergency services is followed by an inpatient admission at the nonparticipating provider.
	(5)	Before submitting a medical claim for reimbursement, the treating nonparticipating provider has requested and received authorization for payment from the Iowa Medicaid enterprise medical services unit. The request shall include the claim listing the emergency and inpatient services.
	b. 	If the conditions listed in paragraph “a” are met as specified, a nonparticipating provider may be reimbursed for covered services provided to the member from the point of emergency room admission to the point of discharge or transfer from the inpatient unit, up to the amount appropriated. This reimbursement does not include emergency or nonemergency transportation services.
	c. 	Care coordination pool. A care coordination pool is established to provide payment for medically necessary services provided to IowaCare members for continuation of care provided by a participating IowaCare hospital. Reimbursement is available from designated care coordination pool funding subject to the following conditions:
	(1)	Payment may be made for continuing care that is related to an IowaCare member’s hospital services as determined in a referral from the participating IowaCare hospital.
	(2)	Payment for continuing care is available to providers that are enrolled in the Iowa medical assistance program, regardless of whether the provider is a participating provider for IowaCare and regardless of the member’s county of residence or medical home assignment.
	(3)	A provider of continuing care that does not participate in the IowaCare program must include information regarding the referral on the claim form.
	(4)	Payment shall be made only for services that are not otherwise covered under the IowaCare program. Payment shall not be made for services that would normally be provided by the IowaCare provider to other non-IowaCare patients.
	(5)	The type, scope, and duration of payable services shall be limited as determined by the department. Payable services are limited to:
	1.	Durable medical equipment.
	2.	Home health services.
	3.	Rehabilitation and therapy services, including intravenous antibiotics and parenteral therapy delivered at home.
	(6)	Types of items or services that are not covered include, but are not limited to:
	1.	Adult diapers.
	2.	Air compressors.
	3.	Bedside commodes.
	4.	Blood pressure kits or machines.
	5.	Cardiac event monitors.
	6.	Continuous passive motion machines.
	7.	Continuous positive air pressure (CPAP) machines.
	8.	Dental care (nonsurgical).
	9.	Eyeglasses, contact lenses, and eye prostheses.
	10.	Gel shoe inserts.
	11.	Hearing aids.
	12.	Heated oxygen.
	13.	Laboratory tests and radiology procedures.
	14.	Oral supplemental formula.
	15.	Outpatient pharmaceuticals not specifically identified in 92.8(7)“c”(5) above.
	16.	Ted hose, Sigvaris stockings, or Jobst stockings.
	17.	Tennis shoes.
	18.	Transcutaneous electrical nerve stimulation (TENS) units.
	19.	Transportation.
	20.	Work boots.
	(7)	All other medical assistance program policies affecting the payable services shall apply, including those regarding prior authorization and level of care determination.
	(8)	Payment is limited to the amount of available funds designated for the care coordination pool.
	d. 	Laboratory test and radiology pool. A funding pool is established to provide payment for medically necessary laboratory tests and radiology services provided to enrolled IowaCare members when authorized by a federally qualified health center that has been designated by the department as part of the IowaCare regional provider network. Payment from the pool shall be subject to the following conditions and limitations:
	(1)	Payment may be made only for laboratory tests or radiology services which the participating federally qualified health center does not otherwise have the means to provide on site.
	(2)	Each participating federally qualified health center shall designate no more than four laboratory testing facilities and no more than four radiology facilities to which the center will refer IowaCare patients for these services. The designated providers must participate in the Iowa medical assistance program. Payment shall be made only to the designated providers.
	(3)	The designated provider must obtain a referral from the participating federally qualified health center for the services and must include information regarding the referral on the claim form.
	(4)	All other medical assistance policies for coverage of laboratory and radiology services shall apply, including requirements for prior authorization.
	(5)	Payment is limited to the amount of available funds designated for the laboratory test and radiology pool. If the amount appropriated for the pool is exhausted, laboratory tests and radiology services ordered by a participating federally qualified health center shall be provided or coordinated by the center.
	92.8(8) Referral protocols. When an IowaCare primary care provider refers the member to an IowaCare specialty provider, the following conditions shall apply:
	a. 	By January 1, 2012, IowaCare providers shall ensure that referral and patient access processes for IowaCare members are no more restrictive than the processes required for any other payor.
	b. 	After an IowaCare provider makes a referral, the IowaCare provider receiving the referral shall report the following information to the referring provider in a manner chosen by the provider receiving the referral:
	(1)	The date an appointment has been scheduled. The appointment date shall be reported to the referring provider within 15 calendar days of receiving the referral. If the referral is denied, the receiving provider shall offer a consultation by telephone, fax, E-mail, or Internet regarding the reason for the denial.
	(2)	If authorized by the IowaCare member, the outcome of the appointment, including whether the appointment was kept, the treatment plan, and any follow-up instructions. This report shall be made no later than 15 calendar days following the appointment date.
	c. 	IowaCare providers shall work together to address any communication or coordination issues that arise. By October 1, 2011, IowaCare providers shall jointly develop and implement:
	(1)	A process to resolve disputes regarding care needs, payment and referrals that includes regular meetings between providers.
	(2)	A process to identify and address quality improvements with a goal to improve coordination of care between primary, specialty and hospital care. This process shall be monitored by the department but be managed and staffed by the providers.
	92.8(9) Other services provided by Broadlawns Medical Center. Broadlawns Medical Center shall be reimbursed for outpatient prescription drugs, podiatry services, optometric services, and durable medical equipment provided to members of the expansion population. Payment is limited to the amount of funds appropriated for this purpose.
[ARC 9135B, IAB 10/6/10, effective 10/1/10; ARC 9728B, IAB 9/7/11, effective 9/1/11; ARC 9890B, IAB 11/30/11, effective 1/4/12; ARC 9996B, IAB 2/8/12, effective 1/19/12; ARC 0200C, IAB 7/11/12, effective 7/1/12; ARC 0760C, IAB 5/29/13, effective 5/8/13]
441—92.9(249A,249J) Claims and reimbursement methodologies.
	92.9(1) Claims. Claims for Medicaid expansion services provided to IowaCare members shall be submitted to the Iowa Medicaid Enterprise, P.O. Box 150001, Des Moines, Iowa 50315, as required by 441—Chapter 80. To facilitate tracking of expenditures, clean claims for IowaCare services shall be submitted to the Iowa Medicaid enterprise within 20 days from ending date of service.
	92.9(2) Payment for hospital services provided by IowaCare network. Effective July 1, 2010:
	a. 	Inpatient hospital services provided by University of Iowa Hospitals and Clinics will be paid based on 100 percent of reasonable and allowable costs.
	(1)	An interim rate based on the Medicaid reimbursement rates and methodologies as of November 30, 2009, shall be used to price submitted claims.
	(2)	At the end of the cost reporting period, a reconciliation will be performed based on the hospital’s CMS-2552 cost report as filed for the payment period and IowaCare claims data as extracted by the department from the Medicaid management information system. The aggregate payments under the interim methodology will be determined and compared to the IowaCare program costs as determined from the hospital’s cost report. For purposes of this rule, aggregate payments include amounts received for the IowaCare program, outlier payments, and patient and third-party payments up to the allowed amount.
	(3)	If the aggregate payments exceed the hospital’s IowaCare costs, the amount by which payments exceed actual costs will be requested and collected from the hospitals.
	(4)	If the aggregate payments are less than actual IowaCare costs, an additional payment equal to the difference will be made to the hospital.
	b. 	Inpatient hospital services provided by Broadlawns Medical Center shall be paid at the Medicaid reimbursement rates and methodologies in effect on November 30, 2009.
	c. 	Outpatient hospital services provided by University of Iowa Hospitals and Clinics or Broadlawns Medical Center shall be paid at the Medicaid reimbursement rates and methodologies in effect on November 30, 2009.
	92.9(3) Payment for nonhospital services provided by IowaCare network. Effective July 1, 2010, IowaCare network providers shall be paid for nonhospital services at the Medicaid fee schedule amounts in effect on November 30, 2009, with the following exceptions:
	a. 	For preventive examination codes, the fee schedule amounts shall be based on the Medicaid physician fee schedule in effect on the date of service.
	b. 	Physician services provided to IowaCare members in a federally qualified health center shall be reimbursed based on the Medicaid physician fee schedule in effect on the date of service, limited to the amount appropriated for the fiscal year.
	c. 	Physician services provided by University of Iowa Hospitals and Clinics physicians to IowaCare members will be reimbursed based on the Medicaid physician fee schedule in effect on the date of service, limited to the amount appropriated for the fiscal year.
	92.9(4) Medical home payments.
	a. 	In addition to any other IowaCare reimbursement, IowaCare providers that meet the medical home standards pursuant to subrule 92.8(6) and have contracted with the department shall receive a monthly medical home payment for each member assigned to the medical home by the department. The medical home payment shall begin the first day of the month following the member’s assignment to the medical home.
	(1)	The medical home payment will be on a per-member, per-month basis in an amount determined by the department, but no more than $4 per member, per month.
	(2)	Effective July 1, 2011, the department shall implement a tiered per-member, per-month payment method that is based on the medical home’s certification level as designated by a nationally recognized medical home accreditation organization.
	b. 	IowaCare medical homes shall be eligible for a performance payment for achieving medical home performance benchmarks designated by the department as specified in the provider’s contract with the department. The performance payment shall be paid by October 31 following the end of the state fiscal year and is in addition to any other IowaCare reimbursement.
	92.9(5) Payment for services provided by nonparticipating hospitals. Nonparticipating hospitals shall be paid at the Medicaid reimbursement rates and methodologies in effect on December 1, 2009, up to the amount appropriated to the nonparticipating provider reimbursement fund created in 2009 Iowa Code Supplement section 249J.24A. No payment shall be made after appropriated funds are exhausted.
	92.9(6) Payment for services provided by other nonparticipating providers. Nonparticipating providers other than hospitals shall be paid at the Medicaid reimbursement rates and methodologies in effect on the date of service.
[ARC 9135B, IAB 10/6/10, effective 10/1/10]
441—92.10(249A,249J) Reporting changes.
	92.10(1) Reporting requirements. 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 obtains other health insurance coverage.
	92.10(2) Untimely report. When a change is not timely reported, any incorrect program expenditures shall be subject to recovery in accordance with 441—92.13(249A,249J).
	92.10(3) Effective date of change. After assistance has been approved, changes reported during the month that affect the member’s eligibility or premium amount 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 certification has expired.
441—92.11(249A,249J) Reapplication. A new application is required when a member’s 12-month certification period has expired or a member is seeking to regain eligibility after cancellation.
	92.11(1) Reapplication at least three days before end of certification period. When a member submits an application before the last three working days of the member’s current certification period, the department shall approve or deny the application by the last working day of the current certification period unless a condition described at 92.4(3)“a” or “b” applies.
	92.11(2) Reapplication within three days of end of certification period or later. When a member submits an application during the last three working days of the member’s current certification period or after the certification period ends, the department shall approve or deny the application as described at 92.4(3).
441—92.12(249A,249J) Terminating eligibility. IowaCare eligibility shall end when any of the following occur:
	1.	The certification period ends.
	2.	The member begins receiving medical assistance in a coverage group under 441—subrules 75.1(1) through 75.1(40).
	3.	The member does not pay premiums as required by 441—92.7(249A,249J).
	4.	The member no longer meets the nonfinancial eligibility requirements under 441—92.2(249A,249J).
	5.	The member is found to have been ineligible at the time the eligibility determination was made due to member misrepresentation or member or agency error.
	6.	The member dies.
441—92.13(249A,249J) Recovery. The department shall recover from a member all Medicaid funds incorrectly expended on behalf of the member and any unpaid premiums in accordance with 441—76.12(249A). For this purpose, unpaid premiums shall be treated as medical assistance incorrectly paid due to client error.
	92.13(1) The department shall recover Medicaid funds expended on behalf of a member and any unpaid premiums from the member’s estate in accordance with 441—76.12(249A).
	92.13(2) Any funds recovered from third parties, including Medicare, by a provider other than a state mental health institute shall be submitted to the Iowa Medicaid enterprise, and an adjustment shall be made to a previously submitted claim.
[ARC 9135B, IAB 10/6/10, effective 10/1/10]
441—92.14(249A,249J) Discontinuance of the program. IowaCare is operated statewide and is funded on a fiscal-year basis (from July through June). When funds are expected to be expended before the end of the fiscal year, enrollment of new members into the program will be discontinued or limited to a reduced scope of services until funding is received for the next fiscal year.
	92.14(1) Suspension of enrollment. To ensure equitable treatment, applications shall be approved on a first-come, first-served basis and enrollment will be suspended when the likely costs of caring for those already enrolled will exhaust the available funding during the year. “First-come, first-served” status is determined by the date the application is approved for eligibility and entered into the computer system.
	92.14(2) Enrollment for limited services. Eligibility or payment for services received cannot be approved beyond the amount of funds available. Because funds are limited, applications may be approved for a reduced scope of services.
441—92.15(249A,249J) 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. However, households will not be entitled to an appeal hearing if the sole basis for denying or limiting services is due to discontinuance or limitation of the program pursuant to 441—92.14(249A,249J).
These rules are intended to implement Iowa Code chapter 249J.
[Filed emergency 6/17/05—published 7/6/05, effective 7/1/05]
[Filed emergency 7/15/05—published 8/3/05, effective 7/15/05]
[Filed 12/14/05, Notices 7/6/05, 8/3/05—published 1/4/06, effective 3/1/06]
[Filed emergency 6/16/06—published 7/5/06, effective 7/1/06]
[Filed 7/14/06, Notice 6/7/06—published 8/2/06, effective 10/1/06]
[Filed 9/19/06, Notice 7/5/06—published 10/11/06, effective 11/16/06]
[Filed emergency 3/14/07—published 4/11/07, effective 4/1/07]
[Filed 5/16/07, Notice 2/14/07—published 6/6/07, effective 8/1/07]
[Filed emergency 7/12/07—published 8/1/07, effective 7/12/07]
[Filed emergency 7/12/07 after Notice 5/23/07—published 8/1/07, effective 8/1/07]
[Filed emergency 9/12/07 after Notice 7/18/07—published 10/10/07, effective 10/1/07]
[Filed 10/10/07, Notice 8/1/07—published 11/7/07, effective 1/1/08]
[Filed emergency 4/9/08—published 5/7/08, effective 4/9/08]
[Filed emergency 6/11/08 after Notice 3/12/08 —published 7/2/08, effective 7/1/08]
[Filed emergency 6/12/08 after Notice 4/23/08—published 7/2/08, effective 7/1/08]
[Filed emergency 7/9/08 after Notice 5/21/08—published 7/30/08, effective 8/1/08]
[Filed Emergency ARC 7667B, IAB 4/8/09, effective 4/1/09]
[Filed ARC 8505B (Notice ARC 8256B, IAB 11/4/09), IAB 2/10/10, effective 4/1/10]
[Filed Emergency After Notice ARC 8500B (Notice ARC 8272B, IAB 11/4/09), IAB 2/10/10, effective 3/1/10]
[Filed Emergency After Notice ARC 9135B (Notice ARC 8977B, IAB 7/28/10), IAB 10/6/10, effective 10/1/10]
[Filed Without Notice ARC 9532B, IAB 6/1/11, effective 7/6/11]
[Filed Emergency ARC 9728B, IAB 9/7/11, effective 9/1/11]
[Filed ARC 9890B (Notice ARC 9729B, IAB 9/7/11), IAB 11/30/11, effective 1/4/12]
[Filed ARC 9982B (Notice ARC 9842B, IAB 11/16/11; Amended Notice ARC 9895B, IAB 11/30/11), IAB 2/8/12, effective 4/1/12]
[Filed Emergency ARC 9996B, IAB 2/8/12, effective 1/19/12]
[Filed Without Notice ARC 0151C, IAB 6/13/12, effective 7/18/12]
[Filed Emergency ARC 0200C, IAB 7/11/12, effective 7/1/12]
[Filed Emergency After Notice ARC 0760C (Notice ARC 0637C, IAB 3/6/13), IAB 5/29/13, effective 5/8/13]
[Filed Emergency After Notice ARC 0759C (Notice ARC 0638C, IAB 3/6/13), IAB 5/29/13, effective 5/8/13]