Senate File 2422 H-8384 Amend Senate File 2422, as amended, passed, and reprinted by 1 the Senate, as follows: 2 1. By striking everything after the enacting clause and 3 inserting: 4 < DIVISION I 5 PUBLIC ASSISTANCE PROGRAMS —— ELIGIBILITY 6 Section 1. NEW SECTION . 234.6A Program eligibility —— 7 residency. 8 1. As used in this section, “public assistance program” 9 means any of the following: 10 a. The state child care assistance program under section 11 237A.13. 12 b. The family investment program under chapter 239B. 13 c. The medical assistance program under chapter 249A. 14 d. The supplemental nutrition assistance program 15 administered by the state pursuant to 7 C.F.R. pts. 270 – 283, 16 as amended. 17 e. The special supplemental nutrition program for women, 18 infants, and children as provided in 42 U.S.C. §1786 et seq. 19 2. a. Unless prohibited under federal law, the department 20 may require from an applicant to a public assistance program 21 proof of at least twelve months of continuous residency within 22 the state including any of the following: 23 (1) A statement from the applicant attesting to the 24 applicant’s reasons for being in the state and length of 25 residency within the state. 26 (2) A statement from the applicant’s employer confirming 27 the applicant’s employment in the state. 28 (3) Any other statement from other persons with knowledge 29 who can attest to the applicant’s reasons for being in the 30 state and length of residency within the state. 31 (4) A copy of the applicant’s most recently filed Iowa state 32 income tax return. 33 b. Paragraph “a” shall not apply to applicants who receive 34 benefits under the federal Social Security Act, 42 U.S.C. §423 35 -1- SF 2422.4100 (2) 91 ak/ko 1/ 13 #1.

et seq. 1 Sec. 2. Section 239.6, subsection 1, paragraph a, 2 subparagraph (4), Code 2026, is amended to read as follows: 3 (4) Information maintained by the United States citizenship 4 and immigration services of the United States department of 5 homeland security , including but not limited to information 6 accessible through the systematic alien verification for 7 entitlements online service . 8 Sec. 3. Section 239.6, subsection 2, Code 2026, is amended 9 by adding the following new paragraph: 10 NEW PARAGRAPH . g. The systematic alien verification for 11 entitlements online service maintained by the United States 12 citizenship and immigration services of the United States 13 department of homeland security or other accessible sources to 14 verify immigration and United States citizenship information. 15 DIVISION II 16 SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM —— ELIGIBILITY 17 Sec. 4. Section 239.1, Code 2026, is amended by adding the 18 following new subsection: 19 NEW SUBSECTION . 01. “Alien” means any person not a citizen 20 or national of the United States. 21 Sec. 5. Section 239.2, Code 2026, is amended to read as 22 follows: 23 239.2 Supplemental nutrition assistance program —— income 24 eligibility. 25 1. a. The department shall establish the gross countable 26 monthly income threshold for the supplemental nutrition 27 assistance program at less than or equal to one hundred sixty 28 percent of the federal poverty level for the household size. 29 b. (1) The department shall consider the income and 30 financial resources of all household members in determining 31 the eligibility and benefit allotment of the household, 32 including all household members determined to be ineligible 33 to participate in SNAP under this section or pursuant to 7 34 U.S.C. §2015(f). Notwithstanding 7 C.F.R. §273.11(c)(3), the 35 -2- SF 2422.4100 (2) 91 ak/ko 2/ 13

individual’s income, deductible expenses, and resources shall 1 be counted, and none shall be prorated. 2 (2) (a) Notwithstanding subparagraph (1), the department 3 shall exclude the earned income of household members who are 4 between the ages of eighteen and twenty-two in determining 5 the eligibility and benefit allotment of the household upon 6 approval of the waiver submitted by the department under 2026 7 Iowa Acts, Senate File 2422 , or successor legislation to 8 provide that for purposes of state administration of SNAP, the 9 earned income under 7 C.F.R. §273.9(c)(7) of household members 10 that meet all the following criteria shall be excluded from 11 household income: 12 (i) Less than twenty-two years of age. 13 (ii) Enrolled in an elementary or secondary school. 14 (iii) Resides with a natural parent, adoptive parent, 15 stepparent, or other household member who exercises parental 16 control over the household member described in subparagraph 17 subdivisions (i) and (ii). 18 (b) The director of health and human services shall 19 notify the Iowa Code editor upon approval of the waiver under 20 subparagraph division (a). 21 c. Pursuant to 7 U.S.C. §2015(f), an individual shall be 22 ineligible to participate in SNAP unless the individual is a 23 resident of the United States and meets at least one of the 24 following criteria: 25 (1) The individual is a citizen or national of the United 26 States. 27 (2) The individual is an alien lawfully admitted for 28 permanent residence as an immigrant, as defined in 8 U.S.C. 29 §1101(a)(15) and 1101(a)(20), excluding alien visitors, 30 tourists, diplomats, students, or other individuals admitted 31 temporarily with no intention of abandoning their residence in 32 a foreign country. 33 (3) The individual is an alien who has been granted the 34 status of Cuban and Haitian entrant, as defined in section 35 -3- SF 2422.4100 (2) 91 ak/ko 3/ 13

501(e) of the federal Refugee Education Assistance Act of 1980, 1 Pub. L. No. 96-422. 2 (4) The individual lawfully resides in the United States in 3 accordance with a compact of free association referred to in 8 4 U.S.C. §1612(b)(2)(G). 5 2. The department shall comply with federal reporting 6 requirements relating to a household member who is determined 7 to be ineligible to participate in SNAP pursuant to 7 C.F.R. 8 §273.4(b). 9 DIVISION III 10 MEDICAID AND IOWA HEALTH AND WELLNESS PLAN —— RETROACTIVE 11 ELIGIBILITY 12 Sec. 6. NEW SECTION . 249A.3B Medicaid —— retroactive 13 eligibility. 14 1. Notwithstanding any provision of state law to the 15 contrary, effective January 1, 2027, in compliance with section 16 71112 of Pub. L. No. 119-21, commonly referred to as the One 17 Big Beautiful Bill Act, the department shall adopt rules to 18 provide that the eligibility of a individual who is a pregnant 19 woman, a child, or a resident of a nursing facility licensed 20 under chapter 135C shall be applied retroactively for no more 21 than two months prior to the month in which the individual 22 submits a completed medical assistance program application. 23 2. The department shall not adopt rules, or submit a 24 request for a waiver or state plan amendment to the centers for 25 Medicare and Medicaid services of the United States department 26 of health and human services, to permit the department to 27 provide medical assistance program eligibility retroactively to 28 any other adult individual except as provided in subsection 1. 29 Sec. 7. Section 249N.4, subsection 5, Code 2026, is amended 30 to read as follows: 31 5. A member is eligible for coverage effective the first day 32 of the month following the month of application for enrollment. 33 The department shall not adopt rules or submit a request for 34 a waiver or state plan amendment to the centers for Medicare 35 -4- SF 2422.4100 (2) 91 ak/ko 4/ 13

and Medicaid services of the United States department of health 1 and human services to permit the department to provide program 2 eligibility prior to the month in which the individual submits 3 a completed application for enrollment. 4 Sec. 8. 2017 Iowa Acts, chapter 174, section 12, subsection 5 15, paragraph a, subparagraph (7), as amended by 2018 Iowa 6 Acts, chapter 1165, section 107, is amended by striking the 7 subparagraph. 8 Sec. 9. MEDICAID RETROACTIVE ELIGIBILITY —— WAIVER. The 9 department of health and human services shall submit a 10 request for a section 1115 demonstration waiver to the centers 11 for Medicare and Medicaid services of the United States 12 department of health and human services for approval to 13 allow, for purposes of state administration of Medicaid, for 14 implementation by the department of no retroactive eligibility 15 for any adult individual who is not a pregnant woman, a child, 16 or a resident of a nursing facility licensed under chapter 17 135C, upon the submission of a completed Medicaid application, 18 instead of three months as required under 42 C.F.R. §435.915. 19 The department shall implement the waiver upon receipt of 20 approval of the waiver by the centers for Medicare and Medicaid 21 services of the United States department of health and human 22 services. 23 DIVISION IV 24 SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM —— ERROR RATE REPORT 25 AND WAIVERS 26 Sec. 10. NEW SECTION . 135.16E Supplemental nutrition 27 assistance program error rate —— report. 28 Beginning with the fiscal quarter that starts on October 29 1, 2026, and every fiscal quarter thereafter, within thirty 30 calendar days of transmission of data to the food and nutrition 31 services of the United States department of agriculture, the 32 department shall submit a report to the general assembly 33 detailing payment error rates associated with the supplemental 34 nutrition assistance program for the immediately preceding 35 -5- SF 2422.4100 (2) 91 ak/ko 5/ 13

fiscal quarter. For the purposes of this section, “supplemental 1 nutrition assistance program” has the same meaning as defined 2 in section 239.1. 3 Sec. 11. FEDERAL SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM 4 —— WAIVER OF EARNED INCOME RULES. 5 1. The department of health and human services shall 6 request a waiver from the food and nutrition services of the 7 United States department of agriculture to provide that, 8 for purposes of state administration of the supplemental 9 nutrition assistance program, the earned income under 7 10 C.F.R. §273.9(c)(7) of household members that meet all of the 11 following criteria shall be excluded from household income: 12 a. Less than twenty-two years of age. 13 b. Enrolled in an elementary or secondary school. 14 c. Resides with a natural parent, adoptive parent, 15 stepparent, or other household member who exercises parental 16 control over the household member described in paragraphs “a” 17 and “b”. 18 2. The department of health and human services shall 19 implement the waiver upon receipt of approval of the waiver 20 from the United States department of agriculture. 21 Sec. 12. FEDERAL SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM 22 —— WAIVER OF ELIGIBILITY VERIFICATION RULES. 23 1. The department of health and human services shall 24 request a waiver from the food and nutrition services of the 25 United States department of agriculture to provide that, for 26 purposes of state administration of the supplemental nutrition 27 assistance program, information from the following automated 28 sources be considered verified upon receipt for purposes 29 of 7 C.F.R. §272.12(c): 30 a. The national directory of new hires maintained by the 31 office of child support services of the United States office 32 for the administration of children and families. 33 b. The unemployment insurance benefits data released by the 34 Iowa department of workforce development. 35 -6- SF 2422.4100 (2) 91 ak/ko 6/ 13

c. The United States social security administration 1 benefits, death, social security number, and citizenship 2 records. 3 d. The residency and identity data released by the United 4 States department of transportation. 5 e. The state incarceration data released by the Iowa 6 department of corrections. 7 f. The automated employment verification service known as 8 work number, or equivalent third-party income verification 9 platforms. 10 2. The department of health and human services shall 11 implement the waiver upon receipt of approval of the waiver 12 from the United States department of agriculture. 13 Sec. 13. FEDERAL SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM 14 —— WAIVER OF EXPUNGEMENT RULES. 15 1. The department of health and human services shall 16 request a waiver from the food and nutrition services of the 17 United States department of agriculture to provide that, for 18 purposes of state administration of the supplemental nutrition 19 assistance program, expungement of benefits on a household’s 20 electronic benefit account under 7 C.F.R. §274.2(i) be 21 permitted after three months or ninety-one days of inactivity, 22 or of benefits remaining, on the electronic benefit account. 23 2. The department of health and human services shall 24 implement the waiver upon receipt of approval of the waiver 25 from the United States department of agriculture. 26 Sec. 14. FEDERAL SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM 27 —— WAIVER OF PAYMENT QUALITY CONTROL SAMPLING PROCEDURES. 28 1. The department of health and human services shall 29 request a waiver from the food and nutrition services of the 30 United States department of agriculture to provide that, for 31 purposes of state administration of the supplemental nutrition 32 assistance program, when reporting the state’s payment error 33 rate as outlined by 7 C.F.R. §275.14, and food and nutrition 34 services handbooks 310 and 311, the department of health and 35 -7- SF 2422.4100 (2) 91 ak/ko 7/ 13

human services be permitted to report the payment error rate 1 based only on errors directly attributable to the department. 2 2. The department of health and human services shall 3 implement the waiver upon receipt of approval of the waiver 4 from the United States department of agriculture. 5 DIVISION V 6 MEDICAID —— EMPLOYED PERSONS WITH DISABILITIES AND EXCEPTIONS 7 TO POLICY REVIEW 8 Sec. 15. Section 249A.3, subsection 2, paragraph a, 9 subparagraph (1), Code 2026, is amended to read as follows: 10 (1) (a) As allowed under 42 U.S.C. 11 §1396a(a)(10)(A)(ii)(XIII), individuals with disabilities, 12 who are less than sixty-five years of age, who are members of 13 families whose income is less than two hundred fifty three 14 hundred percent of the most recently revised official poverty 15 guidelines published by the United States department of health 16 and human services for the family, who have earned income 17 and who are eligible for mandatory medical assistance or 18 optional medical assistance under this section if earnings are 19 disregarded. 20 (b) As allowed by 42 U.S.C. §1396a(r)(2), unearned income 21 shall also be disregarded in determining whether an individual 22 is eligible for assistance under this subparagraph. 23 (c) For the purposes of determining the amount of an 24 individual’s resources under this subparagraph and as allowed 25 by 42 U.S.C. §1396a(r)(2), a maximum of ten thousand dollars 26 of available resources for an individual , and twenty-one 27 thousand dollars of available resources for a couple shall be 28 disregarded, and any additional resources held in a retirement 29 account, in a medical savings account, or in any other account 30 approved under rules adopted by the department shall also be 31 disregarded. 32 (b) (d) Individuals eligible for assistance under this 33 subparagraph, whose individual income exceeds one hundred 34 fifty percent of the official poverty guidelines published 35 -8- SF 2422.4100 (2) 91 ak/ko 8/ 13

by the United States department of health and human services 1 for an individual, shall pay a premium. The amount of the 2 premium shall be based on a sliding fee schedule adopted by 3 rule of the department and shall be based on a percentage of 4 the individual’s income. The maximum premium payable by an 5 individual whose income exceeds one hundred fifty percent of 6 the official poverty guidelines shall be commensurate with 7 the cost of state employees’ group health insurance in this 8 state. The payment to and acceptance by an automated case 9 management system or the department of the premium required 10 under this subparagraph shall not automatically confer initial 11 or continuing program eligibility on an individual. The 12 department shall maintain a page on the department’s internet 13 site where individuals can electronically pay any premium owed 14 by an individual to the department. A premium paid to and 15 accepted by the department’s premium payment process that is 16 subsequently determined to be untimely or to have been paid on 17 behalf of an individual ineligible for the program shall be 18 refunded to the remitter in accordance with rules adopted by 19 the department. Any unpaid premium shall be a debt owed to the 20 department. 21 Sec. 16. Section 249A.4, Code 2026, is amended by adding the 22 following new subsections: 23 NEW SUBSECTION . 15. Submit a report to the general 24 assembly, including the official payment error rate and 25 a summary of the data submitted in the payment error rate 26 measurement report, within thirty calendar days of receipt by 27 the department of the annual official payment error rate from 28 the centers for Medicare and Medicaid services of the United 29 States department of health and human services. 30 NEW SUBSECTION . 16. Submit an annual report to the general 31 assembly on or before October 1 on petitions for a waiver, also 32 referred to by the department as exceptions to policy, of rules 33 governing the Medicaid program filed pursuant to the rules of 34 the department. The report must include all the following for 35 -9- SF 2422.4100 (2) 91 ak/ko 9/ 13

the immediately preceding fiscal year: 1 a. The total number of exceptions to policy granted. 2 b. The cumulative cost of the exceptions to policy that were 3 granted. 4 c. The types of exceptions to policy that were granted. 5 d. Identifiable trends noted by the department including any 6 of the following: 7 (1) The number of exceptions to policy granted in a 8 particular geographic location. 9 (2) The types of Medicaid services that were the basis for 10 exceptions to policy. 11 (3) The Medicaid program eligibility classification of 12 individuals granted exceptions to policy. 13 Sec. 17. MEDICAID EXCEPTIONS TO POLICY REVIEW —— REPORT 14 TO GENERAL ASSEMBLY. The department of health and human 15 services shall conduct a review of petitions for a waiver, 16 also referred to by the department as exceptions to policy, of 17 rules governing the Medicaid program granted by the department 18 between January 1, 2020, and January 1, 2026, and shall submit 19 a report on or before December 15, 2026, of the findings of the 20 review. The report shall include all of the following: 21 1. The total number of exceptions to policy granted. 22 2. The cumulative cost of the exceptions to policy that were 23 granted. 24 3. The types of exceptions to policy that were granted. 25 4. Identifiable trends noted by the department including 26 any of the following: 27 a. The number of exceptions to policy granted in a 28 particular geographic location. 29 b. The types of Medicaid services that were the basis for 30 exceptions to policy. 31 c. The Medicaid program classification of individuals 32 granted exceptions to policy. 33 Sec. 18. CONTINGENT EFFECTIVE DATE. The following takes 34 effect contingent upon receipt of federal approval by the 35 -10- SF 2422.4100 (2) 91 ak/ko 10/ 13

department of health and human services from the centers for 1 Medicare and Medicaid services of the United States department 2 of health and human services: 3 The section of this division of this Act amending section 4 249A.3, subsection 2, paragraph “a”, subparagraph (1), Code 5 2026, relating to Medicaid eligibility for employed individuals 6 with disabilities. 7 DIVISION VI 8 MEDICAID REIMBURSEMENT RATE —— SPECIAL POPULATION NURSING 9 FACILITIES 10 Sec. 19. Section 249A.2, Code 2026, is amended by adding the 11 following new subsection: 12 NEW SUBSECTION . 15. “Special population nursing facility” 13 refers to a nursing facility that serves one of the following 14 populations and has been designated as a special population 15 nursing facility by the department: 16 a. One hundred percent of the residents served are aged 17 thirty and under and require a skilled level of care. 18 b. Seventy percent of the residents served require a skilled 19 level of care for neurological disorders. 20 c. One hundred percent of the residents require care from a 21 facility licensed by the department of inspections, appeals, 22 and licensing as an intermediate care facility for persons with 23 mental illness. 24 d. One hundred percent of the residents require care from a 25 facility licensed by the department of inspections, appeals, 26 and licensing as an intermediate care facility for persons with 27 medical complexity. 28 Sec. 20. NEW SECTION . 249A.38C Medicaid reimbursement rate 29 —— special population nursing facilities. 30 The provider reimbursement rate for each special population 31 nursing facility must be the special population nursing 32 facility’s average allowable per diem costs as adjusted in 33 compliance with applicable federal laws and regulations, 34 including the upper payment limits specified in 42 C.F.R. 35 -11- SF 2422.4100 (2) 91 ak/ko 11/ 13

§447.272(b). If a special population nursing facility subject 1 to this section increases the special population nursing 2 facility’s number of beds or expands to provide additional 3 services on or after July 1, 2026, the reimbursement rate in 4 this section shall apply to such additional beds or services. 5 DIVISION VII 6 MEDICAID —— EXPENDITURE NEUTRALITY 7 Sec. 21. NEW SECTION . 249A.32C Medicaid waivers and state 8 plan amendments —— expenditure neutrality. 9 1. For purposes of this section, unless the context 10 otherwise requires, “expenditure neutral” means that the cost 11 of a federally approved change to an existing, or new request 12 for a, Medicaid waiver or state plan amendment will not result 13 in a net increase in expenditures from the general fund of the 14 state, as certified by an independent actuary retained by the 15 department and confirmed by the legislative services agency. 16 2. The department shall not implement a change to a Medicaid 17 waiver or state plan amendment approved by the centers for 18 Medicare and Medicaid services of the United States department 19 of health and human services if the change is not expenditure 20 neutral, unless expressly approved by the general assembly 21 through legislation prior to the implementation of the change. 22 3. This section shall not apply when the department 23 implements a federally approved change to, or submits a new 24 request for, a Medicaid waiver or state plan amendment that 25 meets any of the following requirements: 26 a. The change or new request was submitted for federal 27 approval prior to July 1, 2026, regardless of whether federal 28 approval has been received by the department by July 1, 2026. 29 b. The change or new request has previously been approved 30 by the general assembly through legislation, or is necessary 31 to administer legislation enacted prior to the department 32 implementing the change or submitting a new request. 33 c. The change or new request is required by federal law 34 or regulation, or is necessary to comply with federal law or 35 -12- SF 2422.4100 (2) 91 ak/ko 12/ 13

regulation. 1 d. The change or new request is necessary to comply with a 2 settlement agreement, consent decree, or other resolution of a 3 state violation of the federal Medicaid program. A change or 4 new request initiated under this paragraph shall be reported 5 to the general assembly, with an estimate of the fiscal impact 6 of the change or new request to the extent it is known, within 7 thirty days of the date of the settlement agreement, consent 8 decree, or other resolution of a state violation of the federal 9 Medicaid program. 10 e. The change or new request involves the development or 11 implementation of actuarially sound capitation rates consistent 12 with 42 C.F.R. §438.4. 13 4. The department may adopt rules pursuant to chapter 17A to 14 administer this section. > 15 2. Title page, by striking lines 1 through 5 and inserting 16 < An Act relating to public assistance programs under the 17 purview of the department of health and human services, 18 including the supplemental nutrition assistance program, 19 Medicaid, the Iowa health and wellness plan, and Medicaid for 20 unemployed persons with disabilities, and including effective 21 date provisions. > 22 ______________________________ HARRIS of Appanoose -13- SF 2422.4100 (2) 91 ak/ko 13/ 13 #2.