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. Effective for applications and recertifications received on or after June 1, 2011, 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	$50	
170% of federal poverty level	$54	
180% of federal poverty level	$57	
190% of federal poverty level	$60	
200% of federal poverty level	$63	

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	$68	
170% of federal poverty level	$72	
180% of federal poverty level	$77	
190% of federal poverty level	$81	
200% of federal poverty level	$85	
	  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.” If the statement is not postmarked by the premium due date, the member or household shall be obligated to pay the premium.
	  a.   	 A partial payment submitted with a written statement indicating that full payment of the monthly premium will be a financial hardship that is postmarked or received on or before the end of the month for which the premium is due shall be considered a request for a hardship exemption. The exemption shall be granted for the balance owed for that month.
	  b.   	 If the postmark is illegible, the date that the hardship declaration is initially received by the department or the department’s designee shall be considered the date of the request.
	  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]