CHAPTER 75CONDITIONS OF ELIGIBILITY[Ch 75, 1973 IDR, renumbered as Ch 90][Prior to 7/1/83, Social Services[770] Ch 75][Prior to 2/11/87, Human Services[498]]PreambleThis chapter establishes the conditions of eligibility for the medical assistance program administered by the department of human services pursuant to Iowa Code chapter 249A and addresses related matters. 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 of Title XIX requirements granted by the Secretary of the U.S. Department of Health and Human Services. 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.DIVISION IGENERAL CONDITIONS OF ELIGIBILITY, COVERAGE GROUPS, AND SSI-RELATED PROGRAMS441—75.1(249A)  Persons covered.    75.1(1)    Persons receiving refugee cash assistance.  Medical assistance shall be available to all recipients of refugee cash assistance. Recipient means a person for whom a refugee cash assistance (RCA) payment is received and includes persons deemed to be receiving RCA. Persons deemed to be receiving RCA are:  a.  Persons denied RCA because the amount of payment would be less than $10.  b.  Rescinded IAB 7/30/08, effective 10/1/08.  c.  Persons who are eligible in every respect for refugee cash assistance (RCA) as provided in 441—Chapter 60, but who do not receive RCA because they did not make application for the assistance.  75.1(2)  Rescinded IAB 10/8/97, effective 12/1/97.  75.1(3)    Persons who are ineligible for Supplemental Security Income (SSI) because of requirements that do not apply under Title XIX of the Social Security Act.  Medicaid shall be available to persons who would be eligible for SSI except for an eligibility requirement used in that program which is specifically prohibited under Title XIX.  75.1(4)    Beneficiaries of Title XVI of the Social Security Act (supplemental security income for the aged, blind and disabled) and mandatory state supplementation.  Medical assistance will be available to all beneficiaries of the Title XVI program and those receiving mandatory state supplementation.  75.1(5)    Persons receiving care in a medical institution who were eligible for Medicaid as of December 31, 1973.  Medicaid shall be available to all persons receiving care in a medical institution who were Medicaid members as of December 31, 1973. Eligibility of these persons will continue as long as they continue to meet the eligibility requirements for the applicable assistance programs (old-age assistance, aid to the blind or aid to the disabled) in effect on December 31, 1973.  75.1(6)    Persons who would be eligible for supplemental security income (SSI), state supplementary assistance (SSA), or the family medical assistance program (FMAP) except for their institutional status.  Medicaid shall be available to persons receiving care in a medical institution who would be eligible for SSI, SSA, or FMAP if they were not institutionalized.  75.1(7)    Persons receiving care in a medical facility who would be eligible under a special income standard.    a.  Subject to paragraphs “b” and “c” below, Medicaid shall be available to persons who:  (1)  Meet level of care requirements as set forth in rules 441—78.3(249A), 441—81.3(249A), and 441—82.7(249A).  (2)  Receive care in a hospital, nursing facility, psychiatric medical institution, intermediate care facility for the mentally retarded, or Medicare-certified skilled nursing facility.  (3)  Have gross countable monthly income that does not exceed 300 percent of the federal supplemental security income benefits for one.  (4)  Either meet all supplemental security income (SSI) eligibility requirements except for income or are under age 21. FMAP policies regarding income and age do not apply when determining eligibility for persons under the age of 21.  b.  For all persons in this coverage group, income shall be considered as provided for SSI-related coverage groups under subrule 75.13(2). In establishing eligibility for persons aged 21 or older for this coverage group, resources shall be considered as provided for SSI-related coverage groups under subrule 75.13(2).  c.  Eligibility for persons in this group shall not exist until the person has been institutionalized for a period of 30 consecutive days and shall be effective no earlier than the first day of the month in which the 30-day period begins. A “period of 30 days” is defined as being from 12 a.m.of the day of admission to the medical institution, and ending no earlier than 12 midnight of the thirtieth day following the beginning of the period.  (1)  A person who enters a medical institution and who dies prior to completion of the 30-day period shall be considered to meet the 30-day period provision.  (2)  Only one 30-day period is required to establish eligibility during a continuous stay in a medical institution. Discharge during a subsequent month, creating a partial month of care, does not affect eligibility for that partial month regardless of whether the eligibility determination was completed prior to discharge.  (3)  A temporary absence of not more than 14 full consecutive days during which the person remains under the jurisdiction of the institution does not interrupt the 30-day period. In order to remain “under the jurisdiction of the institution” a person must first have been physically admitted to the institution.  75.1(8)    Certain persons essential to the welfare of Title XVI beneficiaries.  Medical assistance will be available to the person living with and essential to the welfare of a Title XIX beneficiary provided the essential person was eligible for medical assistance as of December 31, 1973. The person will continue to be eligible for medical assistance as long as the person continues to meet the definition of “essential person” in effect in the public assistance program on December 31, 1973.  75.1(9)    Individuals receiving state supplemental assistance.  Medical assistance shall be available to all recipients of state supplemental assistance as authorized by Iowa Code chapter 249.  75.1(10)    Individuals under age 21 living in a licensed foster care facility or in a private home pursuant to a subsidized adoption arrangement for whom the department has financial responsibility in whole or in part.  When Iowa is responsible for foster care payment for a child pursuant to Iowa Code section 234.35 and rule 441—156.20(234) or has negotiated an adoption assistance agreement for a child pursuant to rule 441—201.5(600), medical assistance shall be available to the child if:  a.  The child lives in Iowa and is not otherwise eligible under a category for which federal financial participation is available; or  b.  The child lives in another state and is not eligible for benefits from the other state pursuant to a program funded under Title XIX of the federal Social Security Act, notwithstanding the residency requirements of 441—75.10(249A) and 441—75.53(249A).  75.1(11)    Individuals living in a court-approved subsidized guardianship home for whom the department has financial responsibility in whole or in part.  When Iowa is responsible for a subsidized guardianship payment for a child pursuant to 441—Chapter 204, medical assistance will be available to the child under this subrule if the child is living in a court-approved subsidized guardianship home and either:  a.  The child lives in Iowa and is not eligible for medical assistance under a category for which federal financial participation is available due to reasons other than:  (1)  Failure to provide information, or  (2)  Failure to comply with other procedural requirements; or  b.  Notwithstanding the residency requirements of 441—75.10(249A) and 441—75.53(249A), the child lives in another state and is not eligible for benefits from the other state pursuant to a program funded under Title XIX of the federal Social Security Act due to reasons other than:  (1)  Failure to provide information, or  (2)  Failure to comply with other procedural requirements.  75.1(12)    Persons ineligible due to October 1, 1972, social security increase.  Medical assistance will be available to individuals and families whose assistance grants were canceled as a result of the increase in social security benefits October 1, 1972, as long as these individuals and families would be eligible for an assistance grant if the increase were not considered.  75.1(13)    Persons who would be eligible for supplemental security income or state supplementary assistance but for social security cost-of-living increases received.  Medical assistance shall be available to all current social security recipients who meet the following conditions:  a.  They were entitled to and received concurrently in any month after April 1977 supplemental security income and social security or state supplementary assistance and social security, and  b.  They subsequently lost eligibility for supplemental security income or state supplementary assistance, and  c.  They would be eligible for supplemental security income or state supplementary assistance if all of the social security cost-of-living increases which they and their financially responsible spouses, parents, and dependent children received since they were last eligible for and received social security and supplemental security income (or state supplementary assistance) concurrently were deducted from their income. Spouses, parents, and dependent children are considered financially responsible if their income would be considered in determining the applicant’s eligibility.  75.1(14)    Family medical assistance program (FMAP).  Medicaid shall be available to children who meet the provisions of rule 441—75.54(249A) and to the children’s specified relatives who meet the provisions of subrule 75.54(2) and rule 441—75.55(249A) if the following criteria are met.  a.  In establishing eligibility of specified relatives for this coverage group, resources are considered in accordance with the provisions of rule 441—75.56(249A) and shall not exceed $2,000 for applicant households or $5,000 for member households. In establishing eligibility for children for this coverage group, resources of all persons in the eligible group, regardless of age, shall be disregarded.  b.  Income is considered in accordance with rule 441—75.57(249A) and does not exceed needs standards established in rule 441—75.58(249A).  c.  Rescinded IAB 11/1/00, effective 1/1/01.  75.1(15)    Child medical assistance program (CMAP).  Medicaid shall be available to persons under the age of 21 if the following criteria are met:  a.  Financial eligibility shall be determined for the family size of which the child is a member using the income standards in effect for the family medical assistance program (FMAP) unless otherwise specified. Income shall be considered as provided in rule 441—75.57(249A). Additionally, the earned income disregards as provided in paragraphs 75.57(2)“a,” “b,” “c,” and “d” shall be allowed for those persons whose income is considered in establishing eligibility for the persons under the age of 21 and whose needs must be included in accordance with paragraph 75.58(1)“a” but who are not eligible for Medicaid. Resources of all persons in the eligible group, regardless of age, shall be disregarded. Unless a family member is voluntarily excluded in accordance with the provisions of rule 441—75.59(249A), family size shall be determined as follows:  (1)  If the person under the age of 21 is pregnant and the pregnancy has been verified in accordance with rule 441—75.17(249A), the unborn child (or children if more than one) is considered a member of the family for purposes of establishing the number of persons in the family.  (2)  A “man-in-the-house” who is not married to the mother of the unborn child is not considered a member of the unborn child’s family for the purpose of establishing the number of persons in the family. His income and resources are not automatically considered, regardless of whether or not he is the legal or natural father of the unborn child. However, income and resources made available to the mother of the unborn child by the “man-in-the-house” shall be considered in determining eligibility for the pregnant individual.  (3)  Unless otherwise specified, when the person under the age of 21 is living with a parent(s), the family size shall consist of all family members as defined by the family medical assistance program in accordance with paragraph 75.57(8)“c” and subrule 75.58(1).Application for Medicaid shall be made by the parent(s) when the person is residing with them. A person shall be considered to be living with the parent(s) when the person is temporarily absent from the parent’s(s’) home as defined in subrule 75.53(4). If the person under the age of 21 is married or has been married, the needs, income and resources of the person’s parent(s) and any siblings in the home shall not be considered in the eligibility determination unless the marriage was annulled.  (4)  When a person is living with a spouse the family size shall consist of that person, the spouse and any of their children, including any unborn children.  (5)  Siblings under the age of 21 who live together shall be considered in the same filing unit for the purpose of establishing eligibility under this rule unless one sibling is married or has been married, in which case, the married sibling shall be considered separately unless the marriage was annulled.  (6)  When a person is residing in a household in which some members are receiving FMAP under the provisions of subrule 75.1(14) or MAC under the provisions of subrule 75.1(28), and when the person is not included in the FMAP or MAC eligible group, the family size shall consist of the person and all other family members as defined above except those in the FMAP or MAC eligible group.  b.  Rescinded IAB 9/6/89, effective 11/1/89.  c.  Rescinded IAB 11/1/89, effective 1/1/90.  d.  A person is eligible for the entire month in which the person’s twenty-first birthday occurs unless the birthday falls on the first day of the month.  e.  Living with a specified relative as provided in subrule 75.54(2) shall not be considered when determining eligibility for persons under this coverage group.  75.1(16)    Children receiving subsidized adoption payments from states providing reciprocal medical assistance benefits.  Medical assistance shall be available to children under the age of 21 for whom an adoption assistance agreement with another state is in effect if all of the following conditions are met:  a.  The child is residing in Iowa in a private home with the child’s adoptive parent or parents.  b.  Benefits funded under Title IV-E of the Social Security Act are not being paid for the child by any state.  c.  Another state currently has an adoption assistance agreement in effect for the child.  d.  The state with the adoption assistance agreement:  (1)  Is a member of the interstate compact on adoption and medical assistance (ICAMA); and  (2)  Provides medical assistance benefits pursuant to a program funded under Title XIX of the Social Security Act, under the optional group at Section 1902(a)(10)(A)(ii)(VIII) of the Act, to children residing in that state (at least until age 18) for whom there is a state adoption assistance agreement in effect with the state of Iowa other than under Title IV-E of the Social Security Act.  75.1(17)    Persons who meet the income and resource requirements of the cash assistance programs.  Medicaid shall be available to the following persons who meet the income and resource guidelines of supplemental security income or refugee cash assistance, but who are not receiving cash assistance:  a.  Aged and blind persons, as defined at subrule 75.13(2).  b.  Disabled persons, as defined at rule 441—75.20(249A).In establishing eligibility for children for this coverage group based on eligibility for SSI, resources of all persons in the eligible group, regardless of age, shall be disregarded. In establishing eligibility for adults for this coverage group, resources shall be considered as provided for SSI-related coverage groups under subrule 75.13(2) or as under refugee cash assistance.  75.1(18)    Persons eligible for waiver services.  Medicaid shall be available to recipients of waiver services as defined in 441—Chapter 83.  75.1(19)    Persons and families terminated from aid to dependent children (ADC) prior to April 1, 1990, due to discontinuance of the $30 or the $30 and one-third earned income disregards.  Rescinded IAB 6/12/91, effective 8/1/91.  75.1(20)    Newborn children.  Medicaid shall be available without an application to newborn children of women who are determined eligible for Medicaid for the month of the child’s birth or for three-day emergency services for labor and delivery for the child’s birth. Effective April 1, 2009, eligibility begins with the month of the birth and continues through the month of the first birthday as long as the child remains an Iowa resident.  a.  The department shall accept any written or verbal statement as verification of the newborn’s birth date unless the birth date is questionable.  b.  In order for Medicaid to continue after the month of the first birthday, a redetermination of eligibility shall be completed.  75.1(21)    Persons and families ineligible for the family medical assistance program (FMAP) in whole or in part because of child or spousal support.  Medicaid shall be available for an additional four months to persons and families who become ineligible for FMAP because of income from child support, alimony, or contributions from a spouse if the person or family member received FMAP in at least three of the six months immediately preceding the month of cancellation.  a.  The four months of extended Medicaid coverage begin the day following termination of FMAP eligibility.  b.  When ineligibility is determined to occur retroactively, the extended Medicaid coverage begins with the first month in which FMAP eligibility was erroneously granted.  c.  Rescinded IAB 10/11/95, effective 10/1/95.  75.1(22)    Refugee spenddown participants.  Rescinded IAB 10/11/95, effective 10/1/95.  75.1(23)    Persons who would be eligible for supplemental security income or state supplementary assistance but for increases in social security benefits because of elimination of the actuarial reduction formula and cost-of-living increases received.  Medical assistance shall be available to all current social security recipients who meet the following conditions. They:  a.  Were eligible for a social security benefit in December of 1983.  b.  Were eligible for and received a widow’s or widower’s disability benefit and supplemental security income or state supplementary assistance for January of 1984.  c.  Became ineligible for supplemental security income or state supplementary assistance because of an increase in their widow’s or widower’s benefit which resulted from the elimination of the reduction factor in the first month in which the increase was paid and in which a retroactive payment of that increase for prior months was not made.  d.  Have been continuously eligible for a widow’s or widower’s benefit from the first month the increase was received.  e.  Would be eligible for supplemental security income or state supplementary assistance benefits if the amount of the increase from elimination of the reduction factor and any subsequent cost-of-living adjustments were disregarded.  f.  Submit an application prior to July 1, 1988, on Form 470-0442, Application for Medical Assistance or State Supplementary Assistance.  75.1(24)    Postpartum eligibility for pregnant women.  Medicaid shall continue to be available, without an application, for 60 days beginning with the last day of pregnancy and throughout the remaining days of the month in which the 60-day period ends, to a woman who had applied for Medicaid prior to the end of her pregnancy and was subsequently determined eligible for Medicaid for the month in which the pregnancy ended.  a.  Postpartum Medicaid shall only be available to a woman who is not eligible for another coverage group after the pregnancy ends.  b.  The woman shall not be required to meet any income or resource criteria during the postpartum period.  c.  When the sixtieth day is not on the last day of the month the woman shall be eligible for Medicaid for the entire month.  75.1(25)    Persons who would be eligible for supplemental security income or state supplementary assistance except that they receive child’s social security benefits based on disability.  Medical assistance shall be available to persons who receive supplemental security income (SSI) or state supplementary assistance (SSA) after their eighteenth birthday because of a disability or blindness which began before age 22 and who would continue to receive SSI or SSA except that they become entitled to or receive an increase in social security benefits from a parent’s account.  75.1(26)  Rescinded IAB 10/8/97, effective 12/1/97.  75.1(27)    Widows and widowers who are no longer eligible for supplemental security income or state supplementary assistance because of the receipt of social security benefits.  Medicaid shall be available to widows and widowers who meet the following conditions:  a.  They have applied for and received or were considered recipients of supplemental security income or state supplementary assistance.  b.  They apply for and receive Title II widow’s or widower’s insurance benefits or any other Title II old age or survivor’s benefits, if eligible for widow’s or widower’s benefits.  c.  Rescinded IAB 5/1/91, effective 4/11/91.  d.  They were not entitled to Part A Medicare hospital insurance benefits at the time of application and receipt of Title II old age or survivor’s benefits. They are not currently entitled to Part A Medicare hospital insurance benefits.  e.  They are no longer eligible for supplemental security income or state supplementary assistance solely because of the receipt of their social security benefits.  75.1(28)    Pregnant women, infants and children (Mothers and Children (MAC)).  Medicaid shall be available to all pregnant women, infants (under one year of age) and children who have not attained the age of 19 if the following criteria are met:  a.  Income.  (1)  Family income shall not exceed 300 percent of the federal poverty level for pregnant women and for infants (under one year of age). Family income shall not exceed 133 percent of the federal poverty level for children who have attained one year of age but who have not attained 19 years of age. Income to be considered in determining eligibility for pregnant women, infants, and children shall be determined according to family medical assistance program (FMAP) methodologies except that the three-step process for determining initial eligibility and the two-step process for determining ongoing eligibility, as described at rule 441—75.57(249A), shall not apply. “Family income” is the income remaining after disregards and deductions have been applied as provided in rule 441—75.57(249A).  (2)  Moneys received as a lump sum, except as specified in subrules 75.56(4) and 75.56(7) and paragraphs 75.57(8)“b” and “c,” shall be treated in accordance with paragraphs 75.57(9)“b” and “c.”  (3)  Unless otherwise specified, when the person under the age of 19 is living with a parent or parents, the family size shall consist of all family members as defined by the family medical assistance program.Application for Medicaid shall be made by the parents when the person is residing with them. A person shall be considered to be living with the parents when the person is temporarily absent from the parent’s home as defined in subrule 75.53(4). If the person under the age of 19 is married or has been married, the needs, income and resources of the person’s parents and any siblings in the home shall not be considered in the eligibility determination unless the marriage was annulled.  (4)  When a person under the age of 19 is living with a spouse, the family size shall consist of that person, the spouse, and any of their children.  (5)  Siblings under the age of 19 who live together shall be considered in the same filing unit for the purpose of establishing eligibility under this subrule unless one sibling is married or has been married, in which case the married sibling shall be considered separately unless the marriage was annulled.  b.  For pregnant women, resources shall not exceed $10,000 per household. In establishing eligibility for infants and children for this coverage group, resources of all persons in the eligible group, regardless of age, shall be disregarded. In establishing eligibility for pregnant women for this coverage group, resources shall be considered in accordance with department of public health 641—subrule 75.4(2).  c.  Rescinded IAB 9/6/89, effective 11/1/89.  d.  Eligibility for pregnant women under this rule shall begin no earlier than the first day of the month in which conception occurred and in accordance with 441—76.5(249A).  e.  The unborn child (children if more than one fetus exists) shall be considered when determining the number of persons in the household.  f.  An infant shall be eligible through the month of the first birthday unless the birthday falls on the first day of the month. A child shall be eligible through the month of the nineteenth birthday unless the birthday falls on the first day of the month.  g.  Rescinded IAB 11/1/89, effective 1/1/90.  h.  When determining eligibility under this coverage group, living with a specified relative as specified at subrule 75.54(2) and the student provisions specified in subrule 75.54(1) do not apply.  i.  A woman who had applied for Medicaid prior to the end of her pregnancy and was subsequently determined eligible for assistance under this coverage group for the month in which her pregnancy ended shall be entitled to receive Medicaid through the postpartum period in accordance with subrule 75.1(24).  j.  If an infant loses eligibility under this coverage group at the time of the first birthday due to an inability to meet the income limit for children or if a child loses eligibility at the time of the nineteenth birthday, but the infant or child is receiving inpatient services in a medical institution, Medicaid shall continue under this coverage group for the duration of the time continuous inpatient services are provided.  75.1(29)    Persons who are entitled to hospital insurance benefits under Part A of Medicare (Qualified Medicare Beneficiary program).  Medicaid shall be available to persons who are entitled to hospital insurance under Part A of Medicare to cover the cost of the Medicare Part A and B premiums, coinsurance and deductibles, providing the following conditions are met:  a.  The person’s monthly income does not exceed 100 percent of the federal poverty level (as defined by the United States Office of Management and Budget and revised annually in accordance with Section 673(2) of the Omnibus Budget Reconciliation Act of 1981) applicable to a family of the size involved.  (1)  The amount of income shall be determined as under the federal Supplemental Security Income (SSI) program.  (2)  Income shall not include any amount of social security income attributable to the cost-of-living increase through the month following the month in which the annual revision of the official poverty line is published.  b.  The person’s resources do not exceed the maximum amount of resources that a person may have to obtain the full low-income subsidy for Medicare Part D drug benefits. The amount of resources shall be determined as under the SSI program unless the person lives and is expected to live at least 30 consecutive days in a medical institution and has a spouse at home. Then the resource determination shall be made according to subrules 75.5(3) and 75.5(4).  c.  The effective date of eligibility is the first of the month after the month of decision.  75.1(30)    Presumptive eligibility for pregnant women.  A pregnant woman who is determined by a qualified provider to be presumptively eligible for Medicaid, based only on her statements regarding family income, shall be eligible for ambulatory prenatal care. Eligibility shall continue until the last day of the month following the month of the presumptive eligibility determination unless the pregnant woman is determined to be ineligible for Medicaid during this period based on a Medicaid application filed either before the presumptive eligibility determination or during this period. In this case, presumptive eligibility shall end on the date Medicaid ineligibility is determined. A pregnant woman who files a Medicaid application but withdraws that application before eligibility is determined has not been determined ineligible for Medicaid. The pregnant woman shall complete Form 470-2927 or 470-2927(S), Health Services Application, in order for the qualified provider to make the presumptive eligibility determination. The qualified provider shall complete Form 470-2629, Presumptive Medicaid Income Calculation, in order to establish that the pregnant woman’s family income is within the prescribed limits of the Medicaid program.If the pregnant woman files a Medicaid application in accordance with rule 441—76.1(249A) by the last day of the month following the month of the presumptive eligibility determination, Medicaid shall continue until a decision of ineligibility is made on the application. Payment of claims for ambulatory prenatal care services provided to a pregnant woman under this subrule is not dependent upon a finding of Medicaid eligibility for the pregnant woman.  a.  A qualified provider is defined as a provider who is eligible for payment under the Medicaid program and who meets all of the following criteria:  (1)  Provides one or more of the following services:
  1. Outpatient hospital services.
  2. Rural health clinic services (if contained in the state plan).
  3. Clinic services furnished by or under the direction of a physician, without regard to whether the clinic itself is administered by a physician.
  (2)  Has been specifically designated by the department in writing as a qualified provider for the purposes of determining presumptive eligibility on the basis of the department’s determination that the provider is capable of making a presumptive eligibility determination based on family income.  (3)  Meets one of the following:
  1. Receives funds under the Migrant Health Centers or Community Health Centers (subsection 329 or subsection 330 of the Public Health Service Act) or the Maternal and Child Health Services Block Grant Programs (Title V of the Social Security Act) or the Health Services for Urban Indians Program (Title V of the Indian Health Care Improvement Act).
  2. Participates in the program established under the Special Supplemental Food Program for Women, Infants, and Children (subsection 17 of the Child Nutrition Act of 1966) or the Commodity Supplemental Food Program (subsection 4(a) of the Agriculture and Consumer Protection Act of 1973).
  3. Participates in a state perinatal program.
  4. Is an Indian health service office or a health program or facility operated by a tribe or tribal organization under the Indian Self-Determination Act.
  b.  The provider shall complete Form 470-2579, Application for Authorization to Make Presumptive Medicaid Eligibility Determinations, and submit it to the department for approval in order to become certified as a provider qualified to make presumptive eligibility determinations. Once the provider has been approved as a provider qualified to make presumptive Medicaid eligibility determinations, Form 470-2582, Memorandum of Understanding Between the Iowa Department of Human Services and a Qualified Provider, shall be signed by the provider and the department.  c.  Once the qualified provider has made a presumptive eligibility determination for a pregnant woman, the provider shall:  (1)  Contact the department to obtain a state identification number for the pregnant woman who has been determined presumptively eligible.  (2)  Notify the department in writing of the determination within five working days after the date the presumptive determination is made. A copy of the Presumptive Medicaid Eligibility Notice of Decision, Form 470-2580 or 470-2580(S), shall be used for this purpose.  (3)  Inform the pregnant woman in writing, at the time the determination is made, that if she chose not to apply for Medicaid on the Health Services Application, Form 470-2927 or 470-2927(S), she has until the last day of the month following the month of the preliminary determination to file an application with the department. A Presumptive Medicaid Eligibility Notice of Decision, Form 470-2580, shall be issued by the qualified provider for this purpose.  (4)  Forward copies of the Health Services Application, Form 470-2927 or 470-2927(S), to the appropriate offices for eligibility determinations if the pregnant woman indicated on the application that she was applying for any of the other programs listed on the application. These copies shall be forwarded within two working days from the date of the presumptive determination.  d.  In the event that a pregnant woman needing prenatal care does not appear to be presumptively eligible, the qualified provider shall inform the pregnant woman that she may file an application at the local department office if she wishes to have a formal determination made.  e.  Presumptive eligibility shall end under any of the following conditions:  (1)  The woman fails to file an application for Medicaid in accordance with rule 441—76.1(249A) by the last day of the month following the month of the presumptive eligibility determination.  (2)  The woman files a Medicaid application by the last day of the month following the month of the presumptive eligibility determination and has been found ineligible for Medicaid.  (3)  Rescinded IAB 5/1/91, effective 7/1/91.  f.  The adequate and timely notice requirements and appeal rights associated with an application that is filed pursuant to rule 441—76.1(249A) shall apply to an eligibility determination made on the Medicaid application. However, notice requirements and appeal rights of the Medicaid program shall not apply to a woman who is:  (1)  Issued a presumptive eligibility decision by a qualified provider.  (2)  Determined to be presumptively eligible by a qualified provider and whose presumptive eligibility ends because the woman fails to file an application by the last day of the month following the month of the initial presumptive eligibility determination.  (3)  Rescinded IAB 5/1/91, effective 7/1/91.  g.  A woman shall not be determined to be presumptively eligible for Medicaid more than once per pregnancy.
  75.1(31)    Persons and families canceled from the family medical assistance program (FMAP) due to the increased earnings of the specified relative in the eligible group.  Medicaid shall be available for a period of up to 12 additional months to families who are canceled from FMAP as provided in subrule 75.1(14) because the specified relative of a dependent child receives increased income from employment.For the purposes of this subrule, “family” shall mean individuals living in the household whose needs and income were included in determining the FMAP eligibility of the household members at the time that the FMAP benefits were terminated. “Family” also includes those individuals whose needs and income would be taken into account in determining the FMAP eligibility of household members if the household were applying in the current month.  a.  Increased income from employment includes:  (1)  Beginning employment.  (2)  Increased rate of pay.  (3)  Increased hours of employment.  b.  In order to receive transitional Medicaid coverage under these provisions, an FMAP family must have received FMAP during at least three of the six months immediately preceding the month in which ineligibility occurred.  c.  The 12 months’ Medicaid transitional coverage begins the day following termination of FMAP eligibility.  d.  When ineligibility is determined to occur retroactively, the transitional Medicaid coverage begins with the first month in which FMAP eligibility was erroneously granted, unless the provisions of paragraph “f” below apply.  e.  Rescinded IAB 8/12/98, effective 10/1/98.  f.  Transitional Medicaid shall not be allowed under these provisions when it has been determined that the member received FMAP in any of the six months immediately preceding the month of cancellation as the result of fraud. Fraud shall be defined in accordance with Iowa Code Supplement section 239B.14.  g.  During the transitional Medicaid period, assistance shall be terminated at the end of the first month in which the eligible group ceases to include a child, as defined by the family medical assistance program.  h.  If the family receives transitional Medicaid coverage during the entire initial six-month period and the department has received, by the twenty-first day of the fourth month, a complete Notice of Decision/Quarterly Income Report, Form 470-2663 or 470-2663(S), Medicaid shall continue for an additional six months, subject to paragraphs “g” and “i” of this subrule.  (1)  If the department does not receive a completed form by the twenty-first day of the fourth month, assistance shall be canceled.  (2)  A completed form is one that has all items answered, is signed, is dated, and is accompanied by verification as required in paragraphs 75.57(1)“f” and 75.57(2)“l.”  i.  Medicaid shall end at the close of the first or fourth month of the additional six-month period if any of the following conditions exists:  (1)  The department does not receive a complete Notice of Decision/Quarterly Income Report, Form 470-2663 or 470-2663(S), by the twenty-first day of the first month or the fourth month of the additional six-month period as required in paragraph 75.1(31)“h,” unless the family establishes good cause for failure to report on a timely basis. Good cause shall be established when the family demonstrates that one or more of the following conditions exist:
  1. There was a serious illness or death of someone in the family.
  2. There was a family emergency or household disaster, such as a fire, flood, or tornado.
  3. The family offers a good cause beyond the family’s control.
  4. There was a failure to receive the department’s notification for a reason not attributable to the family. Lack of a forwarding address is attributable to the family.
  (2)  The specified relative had no earnings in one or more of the previous three months, unless the lack of earnings was due to an involuntary loss of employment, illness, or there were instances when problems could negatively impact the client’s achievement of self-sufficiency as described at 441—subrule 93.133(4).  (3)  It is determined that the family’s average gross earned income, minus child care expenses for the children in the eligible group necessary for the employment of the specified relative, during the immediately preceding three-month period exceeds 185 percent of the federal poverty level as defined by the United States Office of Management and Budget and revised annually in accordance with Section 673(2) of the Omnibus Budget Reconciliation Act of 1981.
  j.  These provisions apply to specified relatives defined at paragraph 75.55(1)“a,” including:  (1)  Any parent who is in the home. This includes parents who are included in the eligible group as well as those who are not.  (2)  A stepparent who is included in the eligible group and who has assumed the role of the caretaker relative due to the absence or incapacity of the parent.  (3)  A needy specified relative who is included in the eligible group.  k.  The timely notice requirements as provided in 441—subrule 76.4(1) shall not apply when it is determined that the family failed to meet the eligibility criteria specified in paragraph “g” or “i” above. Transitional Medicaid shall be terminated beginning with the first month following the month in which the family no longer met the eligibility criteria. An adequate notice shall be provided to the family when any adverse action is taken.
  75.1(32)    Persons and families terminated from refugee cash assistance (RCA) because of income earned from employment.  Refugee medical assistance (RMA) shall be available as long as the eight-month limit for the refugee program is not exceeded to persons who are receiving RMA and who are canceled from the RCA program solely because a member of the eligible group receives income from employment.  a.  An RCA recipient shall not be required to meet any minimum program participation time frames in order to receive RMA coverage under these provisions.  b.  A person who returns to the home after the family became ineligible for RCA may be included in the eligible group for RMA coverage if the person was included on the assistance grant the month the family became ineligible for RCA.  75.1(33)    Qualified disabled and working persons.  Medicaid shall be available to cover the cost of the premium for Part A of Medicare (hospital insurance benefits) for qualified disabled and working persons.  a.  Qualified disabled and working persons are persons who meet the following requirements:  (1)  The person’s monthly income does not exceed 200 percent of the federal poverty level applicable to the family size involved.  (2)  The person’s resources do not exceed twice the maximum amount allowed under the supplemental security income (SSI) program.  (3)  The person is not eligible for any other Medicaid benefits.  (4)  The person is entitled to enroll in Medicare Part A of Title XVIII under Section 1818A of the Social Security Act (as added by Section 6012 of OBRA 1989).  b.  The amount of the person’s income and resources shall be determined as under the SSI program.  75.1(34)    Specified low-income Medicare beneficiaries.  Medicaid shall be available to persons who are entitled to hospital insurance under Part A of Medicare to cover the cost of the Medicare Part B premium, provided the following conditions are met:  a.  The person’s monthly income exceeds 100 percent of the federal poverty level but is less than 120 percent of the federal poverty level (as defined by the United States Office of Management and Budget and revised annually in accordance with Section 673(2) of the Omnibus Budget Reconciliation Act of 1981) applicable to a family of the size involved.  b.  The person’s resources do not exceed the maximum amount of resources that a person may have to obtain the full low-income subsidy for Medicare Part D drug benefits.  c.  The amount of income and resources shall be determined as under the SSI program unless the person lives and is expected to live at least 30 consecutive days in a medical institution and has a spouse at home. Then the resource determination shall be made according to subrules 75.5(3) and 75.5(4). Income shall not include any amount of social security income attributable to the cost-of-living increase through the month following the month in which the annual revision of the official poverty level is published.  d.  The effective date of eligibility shall be as set forth in rule 441—76.5(249A).  75.1(35)    Medically needy persons.    a.    Coverage groups.  Subject to other requirements of this chapter, Medicaid shall be available to the following persons:  (1)  Pregnant women. Pregnant women who would be eligible for FMAP-related coverage groups except for excess income or resources. For FMAP-related programs, pregnant women shall have the unborn child or children counted in the household size as if the child or children were born and living with them.  (2)  FMAP-related persons under the age of 19. Persons under the age of 19 who would be eligible for an FMAP-related coverage group except for excess income.  (3)  CMAP-related persons under the age of 21. Persons under the age of 21 who would be eligible in accordance with subrule 75.1(15) except for excess income.  (4)  SSI-related persons. Persons who would be eligible for SSI except for excess income or resources.  (5)  FMAP-specified relatives. Persons whose income or resources exceed the family medical assistance program’s limit and who are a specified relative as defined at subrule 75.55(1) living with a child who is determined dependent.  b.    Resources and income of all persons considered.    (1)  Resources of all specified relatives and of all potentially eligible individuals living together, except as specified at subparagraph 75.1(35)“b”(2) or who are excluded in accordance with the provisions of rule 441—75.59(249A), shall be considered in determining eligibility of adults. Resources of all specified relatives and of all potentially eligible individuals living together shall be disregarded in determining eligibility of children. Income of all specified relatives and of all potentially eligible individuals living together, except as specified at subparagraph 75.1(35)“b”(2) or who are excluded in accordance with the provisions of rule 441—75.59(249A), shall be considered in determining eligibility.  (2)  The amount of income of the responsible relative that has been counted as available to an FMAP household or SSI individual shall not be considered in determining the countable income for the medically needy eligible group.  (3)  The resource determination shall be according to subrules 75.5(3) and 75.5(4) when one spouse is expected to reside at least 30 consecutive days in a medical institution.  c.    Resources.    (1)  The resource limit for adults in SSI-related households shall be $10,000 per household.  (2)  Disposal of resources for less than fair market value by SSI-related applicants or members shall be treated according to policies specified in rule 441—75.23(249A).  (3)  The resource limit for FMAP- or CMAP-related adults shall be $10,000 per household. In establishing eligibility for children for this coverage group, resources of all persons in the eligible group, regardless of age, shall be disregarded. In establishing eligibility for adults for this coverage group, resources shall be considered according to department of public health 641—subrule 75.4(2).  (4)  The resources of SSI-related persons shall be treated according to SSI policies.  (5)  When a resource is jointly owned by SSI-related persons and FMAP-related persons, the resource shall be treated according to SSI policies for the SSI-related person and according to FMAP policies for the FMAP-related persons.  d.    Income.  All unearned and earned income, unless specifically exempted, disregarded, deducted for work expenses, or diverted shall be considered in determining initial and continuing eligibility.  (1)  Income policies specified in subrules 75.57(1) through 75.57(8) and paragraphs 75.57(9)“b,” “c,” “g,” “h,” and “i” regarding treatment of earned and unearned income are applied to FMAP-related and CMAP-related persons when determining initial eligibility and for determining continuing eligibility unless otherwise specified. The three-step process for determining initial eligibility and the two-step process for determining ongoing eligibility, as described at rule 441—75.57(249A), shall not apply to medically needy persons.  (2)  Income policies as specified in federal SSI regulations regarding treatment of earned and unearned income are applied to SSI-related persons when determining initial and continuing eligibility.  (3)  The monthly income shall be determined prospectively unless actual income is available.  (4)  The income for the certification period shall be determined by adding both months’ net income together to arrive at a total.  (5)  The income for the retroactive certification period shall be determined by adding each month of the retroactive period to arrive at a total.  e.    Medically needy income level (MNIL).    (1)  The MNIL is based on 133 1/3 percent of the schedule of basic needs, as provided in subrule 75.58(2), with households of one treated as households of two, as follows:Number of Persons12345678910MNIL$483$483$566$666$733$816$891$975$1058$1158Each additional person $116  (2)  When determining household size for the MNIL, all potential eligibles and all individuals whose income is considered as specified in paragraph 75.1(35)“b” shall be included unless the person has been excluded according to the provisions of rule 441—75.59(249A).  (3)  The MNIL for the certification period shall be determined by adding both months’ MNIL to arrive at a total. The MNIL for the retroactive certification period, when applicable, shall be determined by adding each month of the retroactive period to arrive at a total.  (4)  The total net countable income for the certification period shall be compared to the total MNIL for the certification period based on family size as specified in subparagraph (2).If the total countable net income is equal to or less than the total MNIL, the medically needy individuals shall be eligible for Medicaid.If the total countable net income exceeds the total MNIL, the medically needy individuals shall not be eligible for Medicaid unless incurred medical expenses equal or exceed the difference between the net income and the MNIL.  (5)  Effective date of approval. Eligibility during the certification period or the retroactive certification period when applicable shall be effective as of the first day of the first month of the certification period or the retroactive certification period when the medically needy income level (MNIL) is met.  f.    Verification of medical expenses to be used in spenddown calculation.  The applicant or member shall submit evidence of medical expenses that are for noncovered Medicaid services and for covered services incurred prior to the certification period to the department on a claim form, which shall be completed by the medical provider. In cases where the provider is uncooperative or where returning to the provider would constitute an unreasonable requirement on the applicant or member, the form shall be completed by the worker. Verification of medical expenses for the applicant or member that are covered Medicaid services and occurred during the certification period shall be submitted by the provider to the Iowa Medicaid enterprise on a claim form. The applicant or member shall inform the provider of the applicant’s or member’s spenddown obligation at the time services are rendered or at the time the applicant or member receives notification of a spenddown obligation. Verification of allowable expenses incurred for transportation to receive medical care as specified in rule 441—78.13(249A) shall be verified on Form 470-0394, Medical Transportation Claim.Applicants who have not established that they met spenddown in the current certification period shall be allowed 12 months following the end of the certification period to submit medical expenses for that period or 12 months following the date of the notice of decision when the certification period had ended prior to the notice of decision.  g.    Spenddown calculation.    (1)  Medical expenses that are incurred during the certification period may be used to meet spenddown. Medical expenses incurred prior to a certification period shall be used to meet spenddown if not already used to meet spenddown in a previous certification period and if all of the following requirements are met. The expenses:
  1. Remain unpaid as of the first day of the certification period.
  2. Are not Medicaid-payable in a previous certification period or the retroactive certification period.
  3. Are not incurred during any prior certification period with the exception of the retroactive period in which the person was conditionally eligible but did not meet spenddown.
Notwithstanding numbered paragraphs “1” through “3,” paid medical expenses from the retroactive period can be used to meet spenddown in the retroactive period or in the certification period for the two months immediately following the retroactive period.
  (2)  Order of deduction. Spenddown shall be adjusted when a bill for a Medicaid-covered service incurred during the certification period has been applied to meet spenddown if a bill for a covered service incurred prior to the certification period is subsequently received. Spenddown shall also be adjusted when a bill for a noncovered Medicaid service is subsequently received with a service date prior to the Medicaid-covered service. Spenddown shall be adjusted when an unpaid bill for a Medicaid-covered service incurred during the certification period has been applied to meet spenddown if a paid bill for a covered service incurred in the certification period is subsequently received with a service date prior to the date of the notice of spenddown status.If spenddown has been met and a bill is received with a service date after spenddown has been met, the bill shall not be deducted to meet spenddown.Incurred medical expenses, including those reimbursed by a state or political subdivision program other than Medicaid, but excluding those otherwise subject to payment by a third party, shall be deducted in the following order:
  1. Medicare and other health insurance premiums, deductibles, or coinsurance charges.
Exception: When some of the household members are eligible for full Medicaid benefits under the Health Insurance Premium Payment Program (HIPP), as provided in rule 441—75.21(249A), the health insurance premium shall not be allowed as a deduction to meet the spenddown obligation of those persons in the household in the medically needy coverage group.
  1. An average statewide monthly standard deduction for the cost of medically necessary personal care services provided in a licensed residential care facility shall be allowed as a deduction for spenddown. These personal care services include assistance with activities of daily living such as preparation of a special diet, personal hygiene and bathing, dressing, ambulation, toilet use, transferring, eating, and managing medication.The average statewide monthly standard deduction for personal care services shall be based on the average per day rate of health care costs associated with residential care facilities participating in the state supplementary assistance program for a 30.4-day month as computed in the Compilation of Various Costs and Statistical Data (Category: All; Type of Care: Residential Care Facility; Location: All; Type of Control: All). The average statewide standard deduction for personal care services used in the medically needy program shall be updated and effective the first day of the first month beginning two full months after the release of the Compilation of Various Costs and Statistical Data for the previous fiscal year.
  2. Medical expenses for necessary medical and remedial services that are recognized under state law but not covered by Medicaid, chronologically by date of submission.
  3. Medical expenses for acupuncture, chronologically by date of submission.
  4. Medical expenses for necessary medical and remedial services that are covered by Medicaid, chronologically by date of submission.
  (3)  When incurred medical expenses have reduced income to the applicable MNIL, the individuals shall be eligible for Medicaid.  (4)  Medical expenses reimbursed by a public program other than Medicaid prior to the certification period shall not be considered a medical deduction.
  h.    Medicaid services.  Persons eligible for Medicaid as medically needy will be eligible for all services covered by Medicaid except:  (1)  Care in a nursing facility or an intermediate care facility for the mentally retarded.  (2)  Care in an institution for mental disease.  (3)  Care in a Medicare-certified skilled nursing facility.  i.    Reviews.  Reviews of eligibility shall be made for SSI-related, CMAP-related, and FMAP-related medically needy members with a zero spenddown as often as circumstances indicate but in no instance shall the period of time between reviews exceed 12 months.SSI-related, CMAP-related, and FMAP-related medically needy persons shall complete Form 470-3118 or 470-3118(S), Medicaid Review, as part of the review process when requested to do so by the department.  j.    Redetermination.  When an SSI-related, CMAP-related, or FMAP-related member who has had ongoing eligibility because of a zero spenddown has income that exceeds the MNIL, a redetermination of eligibility shall be completed to change the member’s eligibility to a two-month certification with spenddown. This redetermination shall be effective the month the income exceeds the MNIL or the first month following timely notice.  (1)  The Health Services Application, Form 470-2927 or 470-2927(S), or the Health and Financial Support Application, Form 470-0462 or Form 470-0466(Spanish), shall be used to determine eligibility for SSI-related medically needy when an SSI recipient has been determined to be ineligible for SSI due to excess income or resources in one or more of the months after the effective date of the SSI eligibility decision.  (2)  All eligibility factors shall be reviewed on redeterminations of eligibility.  k.    Recertifications.  A new application shall be made when the certification period has expired and there has been a break in assistance as defined at rule 441—75.25(249A). When the certification period has expired and there has not been a break in assistance, the person shall use the Medicaid Review, Form 470-3118 or 470-3118(S), to be recertified.  l.    Disability determinations.  An applicant receiving social security disability benefits under Title II of the Social Security Act or railroad retirement benefits based on the Social Security Act definition of disability by the Railroad Retirement Board shall be deemed disabled without any further determination. In other cases under the medically needy program, the department shall conduct an independent determination of disability unless the applicant has been denied supplemental security income benefits based on lack of disability and does not allege either (1) a disabling condition different from or in addition to that considered by the Social Security Administration, or (2) that the applicant’s condition has changed or deteriorated since the most recent Social Security Administration determination.  (1)  In conducting an independent determination of disability, the department shall use the same criteria required by federal law to be used by the Social Security Administration of the United States Department of Health and Human Services in determining disability for purposes of Supplemental Security Income under Title XVI of the Social Security Act. The disability determination services bureau of the division of vocational rehabilitation shall make the initial disability determination on behalf of the department.  (2)  For an independent determination of disability, the applicant or the applicant’s authorized representative shall complete, sign and submit Form 470-4459 or 470-4459(S), Authorization to Disclose Information to the Department of Human Services, and either:
  1. Form 470-2465, Disability Report for Adults, if the applicant is aged 18 or over; or
  2. Form 470-3912, Disability Report for Children, if the applicant is under the age of 18.
  (3)  In connection with any independent determination of disability, the department shall determine whether reexamination of the person’s medical condition will be necessary for periodic redeterminations of eligibility. When reexamination is required, the member or the member’s authorized representative shall complete and submit the same forms as required in subparagraph (2).
  75.1(36)    Expanded specified low-income Medicare beneficiaries.  As long as 100 percent federal funding is available under the federal Qualified Individuals (QI) Program, Medicaid benefits to cover the cost of the Medicare Part B premium shall be available to persons who are entitled to Medicare Part A provided the following conditions are met:  a.  The person is not otherwise eligible for Medicaid.  b.  The person’s monthly income is at least 120 percent of the federal poverty level but is less than 135 percent of the federal poverty level (as defined by the United States Office of Management and Budget and revised annually in accordance with Section 673(2) of the Omnibus Budget Reconciliation Act of 1981) applicable to a family of the size involved.  c.  The person’s resources do not exceed the maximum amount of resources that a person may have to obtain the full low-income subsidy for Medicare Part D drug benefits.  d.  The amount of the income and resources shall be determined the same as under the SSI program unless the person lives and is expected to live at least 30 consecutive days in a medical institution and has a spouse at home. Then the resource determination shall be made according to subrules 75.5(3) and 75.5(4). Income shall not include any amount of social security income attributable to the cost-of-living increase through the month following the month in which the annual revision of the official poverty level is published.  e.  The effective date of eligibility shall be as set forth in rule 441—76.5(249A).  75.1(37)    Home health specified low-income Medicare beneficiaries.  Rescinded IAB 10/30/02, effective 1/1/03.  75.1(38)    Continued Medicaid for disabled children from August 22, 1996.  Medical assistance shall be available to persons who were receiving SSI as of August 22, 1996, and who would continue to be eligible for SSI but for Section 211(a) of the Personal Responsibility and Work Opportunity Act of 1996 (P.L. 104-193).  75.1(39)    Working persons with disabilities.    a.  Medical assistance shall be available to all persons who meet all of the following conditions:  (1)  They are disabled as determined pursuant to rule 441—75.20(249A), except that being engaged in substantial gainful activity will not preclude a determination of disability.  (2)  They are less than 65 years of age.  (3)  They are members of families (including families of one) whose income is less than 250 percent of the most recently revised official federal poverty level for the family. Family income shall include gross income of all family members, less supplemental security income program disregards, exemptions, and exclusions, including the earned income disregards. However, income attributable to a social security cost-of-living adjustment shall be included only in determining eligibility based on a subsequently published federal poverty level.  (4)  They receive earned income from employment or self-employment or are eligible under paragraph 75.1(39)“c.”  (5)  They would be eligible for medical assistance under another coverage group set out in this rule (other than the medically needy coverage groups at subrule 75.1(35)), disregarding all income, up to $10,000 of available resources, and any additional resources held by the disabled individual in a retirement account, a medical savings account, or an assistive technology account. For this purpose, disability shall be determined as under subparagraph 75.1(39)“a”(1) above.  (6)  They have paid any premium assessed under paragraph 75.1(39)“b” below.  b.  Eligibility for a person whose gross income is greater than 150 percent of the federal poverty level for an individual is conditional upon payment of a premium. Gross income includes all earned and unearned income of the conditionally eligible person, except that income attributable to a social security cost-of-living adjustment shall be included only in determining premium liability based on a subsequently published federal poverty level. A monthly premium shall be assessed at the time of application and at the annual review. The premium amounts and the federal poverty level increments above 150 percent of the federal poverty level used to assess premiums will be adjusted annually on August 1.  (1)  Beginning with the month of application, the monthly premium amount shall be established based on projected average monthly income. The monthly premium established shall not be increased for any reason before the next eligibility review. The premium shall not be reduced due to a change in the federal poverty level but may be reduced or eliminated prospectively before the next eligibility review if a reduction in projected average monthly income is verified.  (2)  Eligible persons are required to complete and return Form 470-3118 or 470-3118(S), Medicaid Review, with income information during the twelfth month of the annual enrollment period to determine the premium to be assessed for the next 12-month enrollment period.  (3)  Premiums shall be assessed as follows:IF THE INCOME OF THE APPLICANT IS ABOVE:THE MONTHLYPREMIUM IS:150% of Federal Poverty Level $34165% of Federal Poverty Level $47180% of Federal Poverty Level $56200% of Federal Poverty Level $66225% of Federal Poverty Level $77250% of Federal Poverty Level $89300% of Federal Poverty Level $112350% of Federal Poverty Level $137400% of Federal Poverty Level $161450% of Federal Poverty Level $186550% of Federal Poverty Level $232650% of Federal Poverty Level $280750% of Federal Poverty Level $329850% of Federal Poverty Level $3891000% of Federal Poverty Level $4671150% of Federal Poverty Level $5471300% of Federal Poverty Level $6311480% of Federal Poverty Level $729  (4)  Eligibility is contingent upon the payment of any assessed premiums. Medical assistance eligibility shall not be made effective for a month until the premium assessed for the month is paid. The premium must be paid within three months of the month of coverage or of the month of initial billing, whichever is later, for the person to be eligible for the month.  (5)  When the department notifies the applicant of the amount of the premiums, the applicant shall pay any premiums due as follows:
  1. The premium for each month is due the fourteenth day of the month the premium is to cover. Exceptions: The premium for the month of initial billing is due the fourteenth day of the following month; premiums for any months prior to the month of initial billing are due on the fourteenth day of the third month following the month of billing.
  2. If the fourteenth day falls on a weekend or a state holiday, payment is due the first working day following the holiday or weekend.
  3. When any premium payment due in the month it is to cover is not received by the due date, Medicaid eligibility shall be canceled.
  (6)  Payments received shall be applied in the following order:
  1. To the month in which the payment is received if the premium for the current calendar month is unpaid.
  2. To the following month when the payment is received after a billing statement has been issued for the following month.
  3. To prior months when a full payment has not been received. Payments shall be applied beginning with the most recent unpaid month before the current calendar month, then the oldest unpaid prior month and forward until all prior months have been paid.
  4. When premiums for all months above have been paid, any excess shall be held and applied to any months for which eligibility is subsequently established, as specified in numbered paragraphs “1,” “2,” and “3” above, and then to future months when a premium becomes due.
  5. Any excess on an inactive account shall be refunded to the client after two calendar months of inactivity or of a zero premium or upon request from the client.
  (7)  An individual’s case may be reopened when Medicaid eligibility is canceled for nonpayment of premium. However, the full premium must be received by the department on or before the last day of the month following the month the premium is to cover.  (8)  Premiums may be submitted in the form of money orders or personal checks to the address printed on the coupon attached to Form 470-3902, MEPD Billing Statement.  (9)  Once an individual is canceled from Medicaid due to nonpayment of premiums, the individual must reapply to establish Medicaid eligibility unless the reopening provisions of this subrule apply.  (10)  When a premium due in the month it is to cover is not received by the due date, a notice of decision will be issued to cancel Medicaid. The notice will include reopening provisions that apply if payment is received and appeal rights.  (11)  Form 470-3902, MEPD Billing Statement, shall be used for billing and collection.
  c.  Members in this coverage group who become unable to work due to a change in their medical condition or who lose employment shall remain eligible for a period of six months from the month of the change in their medical condition or loss of employment as long as they intend to return to work and continue to meet all other eligibility criteria under this subrule. Members shall submit Form 470-4856, MEPD Intent to Return to Work, to report on the end of their employment and their intent to return to employment.  d.  For purposes of this subrule, the following definitions apply:
"Assistive technology" is the systematic application of technologies, engineering, methodologies, or scientific principles to meet the needs of and address the barriers confronted by individuals with disabilities in areas that include education, rehabilitation, technology devices and assistive technology services.
"Assistive technology accounts" include funds in contracts, savings, trust or other financial accounts, financial instruments or other arrangements with a definite cash value set aside and designated for the purchase, lease or acquisition of assistive technology, assistive technology devices or assistive technology services. Assistive technology accounts must be held separate from other accounts and funds and must be used to purchase, lease or otherwise acquire assistive technology, assistive technology services or assistive technology devices for the working person with a disability when a physician, certified vocational rehabilitation counselor, licensed physical therapist, licensed speech therapist, or licensed occupational therapist has established the medical necessity of the device, technology, or service and determined the technology, device, or service can reasonably be expected to enhance the individual’s employment.
"Assistive technology device" is any item, piece of equipment, product system or component part, whether acquired commercially, modified or customized, that is used to increase, maintain, or improve functional capabilities or address or eliminate architectural, communication, or other barriers confronted by persons with disabilities.
"Assistive technology service" means any service that directly assists an individual with a disability in the selection, acquisition, or use of an assistive technology device or other assistive technology. It includes, but is not limited to, services referred to or described in the Assistive Technology Act of 1998, 29 U.S.C. 3002(4).
"Family," if the individual is under 18 and unmarried, includes parents living with the individual, siblings under 18 and unmarried living with the individual, and children of the individual who live with the individual. If the individual is 18 years of age or older, or married, “family” includes the individual’s spouse living with the individual and any children living with the individual who are under 18 and unmarried. No other persons shall be considered members of an individual’s family. An individual living alone or with others not listed above shall be considered to be a family of one.
"Medical savings account" means an account exempt from federal income taxation pursuant to Section 220 of the United States Internal Revenue Code (26 U.S.C. § 220).
"Retirement account" means any retirement or pension fund or account, listed in Iowa Code section 627.6(8)“f” as exempt from execution, regardless of the amount of contribution, the interest generated, or the total amount in the fund or account.
  75.1(40)    People who have been screened and found to need treatment for breast or cervical cancer.    a.  Medical assistance shall be available to people who:  (1)  Have been screened for breast or cervical cancer under the Centers for Disease Control and Prevention Breast and Cervical Cancer Early Detection Program established under Title XV of the Public Health Service Act and have been found to need treatment for either breast or cervical cancer (including a precancerous condition);  (2)  Do not otherwise have creditable coverage, as that term is defined by the Health Insurance Portability and Accountability Act (HIPAA) (42 U.S.C. Section 300gg(c)(1)), and are not eligible for medical assistance under Iowa Code section 249A.3(1); and  (3)  Are under the age of 65.  b.  Eligibility established under paragraph “a” continues until the person is:  (1)  No longer receiving treatment for breast or cervical cancer;  (2)  No longer under the age of 65; or  (3)  Covered by creditable coverage or eligible for medical assistance under Iowa Code section 249A.3(1).  c.  Presumptive eligibility. A person who has been screened for breast or cervical cancer under the Centers for Disease Control and Prevention Breast and Cervical Cancer Early Detection Program established under Title XV of the Public Health Service Act, who has been found to need treatment for either breast or cervical cancer (including a precancerous condition), and who is determined by a qualified provider to be presumptively eligible for medical assistance under paragraph “a” shall be eligible for medical assistance until the last day of the month following the month of the presumptive eligibility determination if no Medicaid application is filed in accordance with rule 441—76.1(249A) by that day or until the date of a decision on a Medicaid application filed in accordance with rule 441—76.1(249A) by the last day of the month following the month of the presumptive eligibility determination, whichever is earlier.The person shall complete Form 470-2927 or 470-2927(S), Health Services Application, in order for the qualified provider to make the presumptive eligibility determination. Presumptive eligibility shall begin no earlier than the date the qualified Medicaid provider determines eligibility.Payment of claims for services provided to a person under this paragraph is not dependent upon a finding of Medicaid eligibility for the person.  (1)  A provider who is qualified to determine presumptive eligibility is defined as a provider who:
  1. Is eligible for payment under the Medicaid program; and
  2. Either:
  • Has been named lead agency for a county or regional local breast and cervical cancer early detection program under a contract with the department of public health; or
  • Has a cooperative agreement with the department of public health under the Centers for Disease Control and Prevention Breast and Cervical Cancer Early Detection Program established under Title XV of the Public Health Service Act to receive reimbursement for providing breast or cervical cancer screening or diagnostic services to participants in the Care for Yourself Breast and Cervical Cancer Early Detection Program; and
    1. Has made application and has been specifically designated by the department in writing as a qualified provider for the purpose of determining presumptive eligibility under this rule.
      (2)  The provider shall complete Form 470-3864, Application for Authorization to Make Presumptive Medicaid Eligibility Determinations (BCCT), and submit it to the department for approval in order to be designated as a provider qualified to make presumptive eligibility determinations. Once the department has approved the provider’s application, the provider and the department shall sign Form 470-3865, Memorandum of Understanding with a Qualified Provider for People with Breast or Cervical Cancer Treatment. When both parties have signed the memorandum, the department shall designate the provider as a qualified provider and notify the provider.  (3)  When a qualified provider has made a presumptive eligibility determination for a person, the provider shall:
    1. Contact the department to obtain a state identification number for the person who has been determined presumptively eligible.
    2. Notify the department in writing of the determination within five working days after the date the presumptive eligibility determination is made. The provider shall use a copy of Form 470-2580 or 470-2580(S), Presumptive Medicaid Eligibility Notice of Decision, for this purpose.
    3. Inform the person in writing, at the time the determination is made, that if the person has not applied for Medicaid on Form 470-2927 or 470-2927(S), Health Services Application, the person has until the last day of the month following the month of the preliminary determination to file the application with the department. The qualified provider shall use Form 470-2580 or 470-2580(S), Presumptive Medicaid Eligibility Notice of Decision, for this purpose.
    4. Forward copies of Form 470-2927 or 470-2927(S), Health Services Application, to the appropriate department office for eligibility determination if the person indicated on the application that the person was applying for any of the other programs. The provider shall forward these copies and proof of screening for breast or cervical cancer under the Centers for Disease Control and Prevention Breast and Cervical Cancer Early Detection Program within two working days from the date of the presumptive eligibility determination.
      (4)  In the event that a person needing care does not appear to be presumptively eligible, the qualified provider shall inform the person that the person may file an application at the county department office if the person wishes to have an eligibility determination made by the department.  (5)  Presumptive eligibility shall end under either of the following conditions:
    1. The person fails to file an application for Medicaid in accordance with rule 441—76.1(249A) by the last day of the month following the month of the presumptive eligibility determination.
    2. The person files a Medicaid application by the last day of the month following the month of the presumptive eligibility determination and is found ineligible for Medicaid.
      (6)  Adequate and timely notice requirements and appeal rights shall apply to an eligibility determination made on a Medicaid application filed pursuant to rule 441—76.1(249A). However, notice requirements and appeal rights of the Medicaid program shall not apply to a person who is:
    1. Denied presumptive eligibility by a qualified provider.
    2. Determined to be presumptively eligible by a qualified provider and whose presumptive eligibility ends because the person fails to file an application by the last day of the month following the month of the presumptive eligibility determination.
      (7)  A new period of presumptive eligibility shall begin each time a person is screened for breast or cervical cancer under the Centers for Disease Control and Prevention Breast and Cervical Cancer Early Detection Program established under Title XV of the Public Health Service Act, is found to need treatment for breast or cervical cancer, and files Form 470-2927 or 470-2927(S), Health Services Application, with a qualified provider.
      75.1(41)    Persons eligible for family planning services under demonstration waiver.  Rescinded IAB 10/11/17, effective 10/1/17.  75.1(42)    Medicaid for independent young adults.  Medical assistance shall be available, as assistance related to the family medical assistance program, to a person who left a foster care placement on or after May 1, 2006, and meets all of the following conditions:  a.  The person is at least 18 years of age and under 21 years of age.  b.  On the person’s eighteenth birthday, the person resided in foster care and Iowa was responsible for the foster care payment pursuant to Iowa Code section 234.35.  c.  The person is not a mandatory household member or receiving Medicaid benefits under another coverage group.  d.  The person has income below 200 percent of the most recently revised federal poverty level for the person’s household size.  (1)  “Household” shall mean the person and any of the following people who are living with the person and are not active on another Medicaid case:
    1. The person’s own children;
    2. The person’s spouse; and
    3. Any children of the person’s spouse who are under the age of 18 and unmarried.
    No one else shall be considered a member of the person’s household. A person who lives alone or with others not listed above, including the person’s parents, shall be considered a household of one.
      (2)  The department shall determine the household’s countable income pursuant to rule 441—75.57(249A). Twenty percent of earned income shall be disregarded.  (3)  A person found to be income-eligible upon application or upon annual redetermination of eligibility shall remain income-eligible for 12 months regardless of any change in income or household size.
      75.1(43)    Medicaid for children with disabilities.  Medical assistance shall be available to children who meet all of the following conditions on or after January 1, 2009:  a.  The child is under 19 years of age.  b.  The child is disabled as determined pursuant to rule 441—75.20(249A) based on the disability standards for children used for Supplemental Security Income (SSI) benefits under Title XVI of the Social Security Act, but without regard to any income or asset eligibility requirements of the SSI program.   c.  The child is enrolled in any group health plan available through the employer of a parent living in the same household as the child if the employer contributes at least 50 percent of the total cost of annual premiums for that coverage. The parent shall enroll the child and pay any employee premium required to maintain coverage for the child.  d.  The child’s household has income at or below 300 percent of the federal poverty level applicable to a family of that size.  (1)  For this purpose, the child’s household shall include any of the following persons who are living with the child and are not receiving Medicaid on another case:
    1. The child’s parents.
    2. The child’s siblings under the age of 19.
    3. The child’s spouse.
    4. The child’s children.
    5. The children of the child’s spouse.
      (2)  Only those persons identified in subparagraph (1) shall be considered a member of the child’s household. A person who receives medically needy coverage with a spenddown or limited benefits such as Medicare savings programs only is not considered to be “receiving Medicaid” for the purposes of subparagraph (1). A child who lives alone or with persons not identified in subparagraph (1) shall be considered as having a household of one.  (3)  For this purpose, the income of all persons included in the child’s household shall be determined as provided for SSI-related groups under subrule 75.13(2).  (4)  The federal poverty levels used to determine eligibility shall be revised annually on April 1.
      75.1(44)    Presumptive eligibility for children.  Medical assistance shall be available to children under the age of 19 who are determined by a qualified entity to be presumptively eligible for medical assistance pursuant to this subrule.  a.    Qualified entity.  A “qualified entity” is an entity described in paragraphs (1) through (10) of the definition of the term at 42 CFR 435.1101, as amended to October 1, 2008, that:  (1)  Has been determined by the department to be capable of making presumptive determinations of eligibility, and   (2)  Has signed an agreement with the department as a qualified entity.   b.    Application process.  Families requesting assistance for children under this subrule shall apply with a qualified entity using the form specified in 441—paragraph 76.1(1)“f.” The qualified entity shall use the department’s web-based system to make the presumptive eligibility determination, based on the information provided in the application.  (1)  All presumptive eligibility applications shall be forwarded to the department for a full Medicaid or HAWK-I eligibility determination, regardless of the child’s presumptive eligibility status.  (2)  The date a valid application was received by the qualified entity establishes the date of application for purposes of determining the effective date of Medicaid or HAWK-I eligibility unless the qualified entity received the application on a weekend or state holiday. Applications received by the qualified entity on a weekend or a state holiday shall be considered to be received on the first business day following the weekend or state holiday.  (3)  The qualified entity shall issue Form 470-2580 or 470-2580(S), Presumptive Medicaid Eligibility Notice of Decision, to inform the applicant of the decision on the application as soon as possible but no later than within two working days after the date the determination is made.  (4)  Timely and adequate notice requirements and appeal rights of the Medicaid program shall not apply to presumptive eligibility decisions made by a qualified entity.  c.    Eligibility requirements.  To be determined presumptively eligible for medical assistance, a child shall meet the following eligibility requirements.  (1)  Age. The child must be under the age of 19.  (2)  Household income. Household income must be less than 300 percent of the federal poverty level for a household of the same size. For this purpose, the household shall include the applicant child and any sibling (of whole or half blood, or adoptive), spouse, parent, or stepparent living with the applicant child. This determination shall be based on the household’s gross income, with no deductions, diversions, or disregards.  (3)  Citizenship or qualified alien status. The child must be a citizen of the United States or a qualified alien as defined in subrule 75.11(2).  (4)  Iowa residency. The child must be a resident of Iowa.  (5)  Prior presumptive eligibility. A child shall not be determined presumptively eligible more than once in a 12-month period. The first month of the 12-month period begins with the month the application is received by the qualified entity.  d.    Period of presumptive eligibility.  Presumptive eligibility shall begin with the date that presumptive eligibility is determined and shall continue until the earliest of the following dates:  (1)  The last day of the next calendar month;  (2)  The day the child is determined eligible for Medicaid;  (3)  The last day of the month that the child is determined eligible for HAWK-I; or  (4)  The day the child is determined ineligible for Medicaid and HAWK-I. Withdrawal of the Medicaid or HAWK-I application before eligibility is determined shall not affect the child’s eligibility during the presumptive period.  e.    Services covered.  Children determined presumptively eligible under this subrule shall be entitled to all Medicaid-covered services, including early and periodic screening, diagnosis, and treatment (EPSDT) services. Payment of claims for Medicaid services provided to a child during the presumptive eligibility period, including EPSDT services, is not dependent upon a determination of Medicaid or HAWK-I eligibility by the department.  75.1(45)    Medicaid for former foster care youth.  Effective January 1, 2014, medical assistance shall be available to a person who meets all of the following conditions:  a.  The person is at least 18 years of age (or such higher age to which foster care is provided to the person) and under 26 years of age;  b.  The person is not described in or enrolled under any of Subclauses (I) through (VII) of Section 1902(a)(10)(A)(i) of Title XIX of the Social Security Act or is described in any of such subclauses but has income that exceeds the level of income applicable under Iowa’s state Medicaid plan for eligibility to enroll for medical assistance under such subclause;  c.  The person was in foster care under the responsibility of Iowa on the date of attaining 18 years of age or such higher age to which foster care is provided; and  d.  The person was enrolled in the Iowa Medicaid program under Title XIX of the Social Security Act while in such foster care.This rule is intended to implement Iowa Code sections 249A.3, 249A.4 and 249A.6.
    Related ARC(s): 7741B, 7833B, 7929B, 7931B, 8095B, 8260B, 8261B, 8439B, 8503B, 8713B, 8897B, 9581B, 9647B, 9956B, 0149C, 0579C, 0820C, 0990C, 1134C, 1482C, 2029C, 2557C, 3094C, 3353C, 3354C, 3549C, 3550C, 3873C, 4574C441—75.2(249A)  Medical resources.  Medical resources include health and accident insurance, eligibility for care through the Department of Veterans Affairs, specialized child health services, Title XVIII of the Social Security Act (Medicare), and other resources for meeting the cost of medical care which may be available to the member. These resources must be used when reasonably available.  75.2(1)  The department shall approve payment only for those services or that part of the cost of a given service for which no medical resources exist unless pay and chase provisions as defined in rule 441—75.25(249A) are applicable.  a.  Persons who have been approved by the Social Security Administration for Supplemental Security Income shall complete Form 470-0364, 470-0364(M), 470-0364(MS), or 470-0364(S), SSI Medicaid Information, and return it to the department.  b.  Persons eligible for Part B of the Medicare program shall make assignment to the department on Form 470-0364, 470-0364(M), 470-0364(MS), or 470-0364(S), SSI Medicaid Information.  75.2(2)  As a condition of eligibility for medical assistance, a person who has the legal capacity to execute an assignment shall do all of the following:  a.  Assign to the department any rights to payments of medical care from any third party to the extent that payment has been made under the medical assistance program. The applicant’s signature on any form listed in 441—subrule 76.1(1) shall constitute agreement to the assignment. The assignment shall be effective for the entire period for which medical assistance is paid.  b.  Cooperate with the department in obtaining third-party payments. The member or one acting on the member’s behalf shall:  (1)  File a claim or submit an application for any reasonably available medical resource, and  (2)  Cooperate in the processing of the claim or application.   c.  Cooperate with the department in identifying and providing information to assist the department in pursuing any third party who may be liable to pay for medical care and services available under the medical assistance program.  75.2(3)  Good cause for failure to cooperate in the filing or processing of a claim or application shall be considered to exist when the member, or one acting on behalf of a minor, or of a legally incompetent adult member, is physically or mentally incapable of cooperation. Good cause shall be considered to exist when cooperation is reasonably anticipated to result in:  a.  Physical or emotional harm to the member for whom medical resources are being sought.  b.  Physical or emotional harm to the parent or payee, acting on the behalf of a minor, or of a legally incompetent adult member, for whom medical resources are being sought.  75.2(4)  Failure to cooperate as required in subrule 75.2(2) without good cause as defined in subrule 75.2(3) shall result in the termination of medical assistance benefits. The department shall make the determination of good cause based on information and evidence provided by the member or by one acting on the member’s behalf.  a.  The medical assistance benefits of a minor or a legally incompetent adult member shall not be terminated for failure to cooperate in reporting medical resources.  b.  When a parent or payee acting on behalf of a minor or legally incompetent adult member fails to file a claim or application for reasonably available medical resources or fails to cooperate in the processing of a claim or application without good cause, the medical assistance benefits of the parent or payee shall be terminated.This rule is intended to implement Iowa Code sections 249A.4, 249A.5 and 249A.6.Related ARC(s): 7546B, 8503B, 8785B441—75.3(249A)  Acceptance of other financial benefits.  An applicant or member shall take all steps necessary to apply for and, if entitled, accept any income or resources for which the applicant or member may qualify, unless the applicant or member can show an incapacity to do so. Sources of benefits may be, but are not limited to, annuities, pensions, retirement or disability benefits, veterans’ compensation and pensions, old-age, survivors, and disability insurance, railroad retirement benefits, black lung benefits, or unemployment compensation.  75.3(1)  When it is determined that the supplemental security income (SSI)-related applicant or member may be entitled to other cash benefits, the department shall send a Notice Regarding Acceptance of Other Benefits, Form 470-0383, to the applicant or member.  75.3(2)  The SSI-related applicant or member must express an intent to apply or refuse to apply for other benefits within ten calendar days from the date the notice is issued. A signed refusal to apply or failure to return the form shall result in denial of the application or cancellation of Medicaid unless the applicant or member is mentally or physically incapable of filing the claim for other cash benefits.  75.3(3)  When the SSI-related applicant or member is physically or mentally incapable of filing the claim for other cash benefits, the department shall request the person acting on behalf of the member to pursue the potential benefits.  75.3(4)  The SSI-related applicant or member shall cooperate in applying for the other benefits. Failure to timely secure the other benefits shall result in cancellation of Medicaid.Exception: An applicant or member shall not be required to apply for supplementary security income to receive Medicaid under subrule 75.1(17).This rule is intended to implement Iowa Code sections 249A.3 and 249A.4.441—75.4(249A)  Medical assistance lien.    75.4(1)  When the medical assistance program pays for a member’s medical care or expenses, the department shall have a lien upon all monetary claims which the member may have against third parties for those expenses. Monetary claims shall include medical malpractice claims for injuries sustained on or after July 1, 2011. The lien shall be to the extent of the medical assistance payments only.  a.  A lien is not effective unless the department files a notice of lien with the clerk of the district court in the county where the member resides and with the member’s attorney when the member’s eligibility for medical assistance is established. The notice of lien shall be filed before the third party has concluded a final settlement with the member, the member’s attorney, or other representative.  b.  The third party shall obtain a written determination from the department concerning the amount of the lien before a settlement is deemed final.  (1)  A compromise, including, but not limited to, notification, settlement, waiver or release of a claim, does not defeat the department’s lien except pursuant to the written agreement of the director or the director’s designee under which the department would receive less than full reimbursement of the amounts it expended.  (2)  A settlement, award, or judgment structured in any manner not to include medical expenses or an action brought by a member or on behalf of a member which fails to state a claim for recovery of medical expenses does not defeat the department’s lien if there is any recovery on the member’s claim.  c.  All notifications to the department required by law shall be directed to the Iowa Medicaid Enterprise, Revenue Collection Unit, P.O. Box 36475, Des Moines, Iowa 50315. Notification shall be considered made as of the time the notification is deposited so addressed, postage prepaid, in the United States Postal Service system.  75.4(2)  The department may pursue its rights to recover either directly from any third party or from any recovery obtained by or on behalf of any member. If a member incurs the obligation to pay attorney fees and court costs for the purpose of enforcing a monetary claim to which the department has a lien under this section, upon the receipt of the judgment or settlement of the total claim, of which the lien for medical assistance payments is a part, the court costs and reasonable attorney fees shall first be deducted from this total judgment or settlement. One-third of the remaining balance shall then be deducted and paid to the member. From the remaining balance, the lien of the department shall be paid. Any amount remaining shall be paid to the member. An attorney acting on behalf of a member for the purpose of enforcing a claim to which the department has a lien shall not collect from the member any amount as attorney fees which is in excess of the amount which the attorney customarily would collect on claims not subject to this rule. The department will provide computer-generated documents or claim forms describing the services for which it has paid upon request of any affected member or the member’s attorney. The documents may also be provided to a third party where necessary to establish the extent of the department’s claim.  75.4(3)  In those cases where appropriate notification is not given to the department or where the department’s recovery rights are otherwise adversely affected by an action of the member or one acting on the member’s behalf, medical assistance benefits shall be terminated. The medical assistance benefits of a minor child or a legally incompetent adult member shall not be terminated. Subsequent eligibility for medical assistance benefits shall be denied until an amount equal to the unrecovered claim has been reimbursed to the department or the individual produces documentation of incurred medical expense equal to the amount of the unrecovered claim. The incurred medical expense shall not be paid by the medical assistance program.  a.  The client, or one acting on the client’s behalf, shall provide information and verification as required to establish the availability of medical or third-party resources.  b.  Rescinded IAB 9/4/91, effective 11/1/91.  c.  The client or person acting on the client’s behalf shall complete Form 470-2826, Supplemental Insurance Questionnaire, in a timely manner at the time of application, when any change in medical resources occurs during the application period, and when any changes in medical resources occur after the application is approved.A report shall be considered timely when made within ten days from:  (1)  The date that health insurance begins, changes, or ends.  (2)  The date that eligibility begins for care through the Department of Veterans Affairs, specialized child health services, Title XVIII of the Social Security Act (Medicare) and other resources.  (3)  The date the client, or one acting on the client’s behalf, files an insurance claim against an insured third party, for the payment of medical expenses that otherwise would be paid by Medicaid.  (4)  The date the member, or one acting on the member’s behalf, retains an attorney with the expectation of seeking restitution for injuries from a possibly liable third party, and the medical expenses resulting from those injuries would otherwise be paid by Medicaid.  (5)  The date that the member, or one acting on the member’s behalf, receives a partial or total settlement for the payment of medical expenses that would otherwise be paid by Medicaid.The member may report the change in person, by telephone, by mail or by using the Ten-Day Report of Change, Form 470-0499 or 470-0499(S), which is mailed with the Family Investment Program warrants and is issued to the client when Medicaid applications are approved, when annual reviews are completed, when a completed Ten-Day Report of Change is submitted, and when the client requests a form.  d.  The member, or one acting on the member’s behalf, shall complete the Priority Leads Letter, Form 470-0398, when the department has reason to believe that the member has sustained an accident-related injury. Failure to cooperate in completing and returning this form, or in giving complete and accurate information, shall result in the termination of Medicaid benefits.  e.  When the recovery rights of the department are adversely affected by the actions of a parent or payee acting on behalf of a minor or legally incompetent adult member, the Medicaid benefits of the parent or payee shall be terminated. When a parent or payee fails to cooperate in completing or returning the Priority Leads Letter, Form 470-0398, or the Supplemental Insurance Questionnaire, Form 470-2826, or fails to give complete and accurate information concerning the accident-related injuries of a minor or legally incompetent adult member, the department shall terminate the Medicaid benefits of the parent or payee.  f.  The member, or one acting on the member’s behalf, shall refund to the department from any settlement or payment received the amount of any medical expenses paid by Medicaid. Failure of the member to do so shall result in the termination of Medicaid benefits. In those instances where a parent or payee, acting on behalf of a minor or legally incompetent adult member, fails to refund a settlement overpayment to the department, the Medicaid benefits of the parent or payee shall be terminated.  75.4(4)  Third party and provider responsibilities.  a.  The health care services provider shall inform the department by appropriate notation on the Health Insurance Claim, Form CMS-1500, that other coverage exists but did not cover the service being billed or that payment was denied.  b.  The health care services provider shall notify the department in writing by mailing copies of any billing information sent to a member, an attorney, an insurer or other third party after a claim has been submitted to or paid by the department.  c.  An attorney representing an applicant for medical assistance or a past or present Medicaid member on a claim to which the department has filed a lien under this rule shall notify the department of the claim of which the attorney has actual knowledge, before filing a claim, commencing an action or negotiating a settlement offer. Actual knowledge shall include the notice to the attorney pursuant to subrule 75.4(1). The mailing and deposit in a United States post office or public mailing box of the notice, addressed to the department at its state or local office location, is adequate legal notice of the claim.  75.4(5)  Department’s lien.  a.  The department’s liens are valid and binding on an attorney, insurer or other third party only upon notice by the department or unless the attorney, insurer or other third party has actual notice that the member is receiving medical assistance from the department and only to the extent that the attorney, insurer or third party has not made payment to the member or an assignee of the member prior to the notice.Any information released to an attorney, insurer or other third party, by the health care services provider, that indicates that reimbursement from the state was contemplated or received, shall be construed as giving the attorney, insurer or other third party actual knowledge of the department’s involvement. For example, information supplied by a health care services provider which indicates medical assistance involvement shall be construed as showing involvement by the department under Iowa Code section 249A.6. Payment of benefits by an insurer or third party pursuant to the rights of the lienholder in this rule discharges the attorney, insurer or other third party from liability to the member or the member’s assignee to the extent of the payment to the department.  b.  When the department has reason to believe that an attorney is representing a member on a claim to which the department filed a lien under this rule, the department shall issue notice to that attorney of the department’s lien rights by mailing the Notice of Medical Assistance Lien, Form 470-3030, to the attorney.  c.  When the department has reason to believe that an insurer is liable for the costs of a member’s medical expenses, the department shall issue notice to the insurer of the department’s lien rights by mailing the Notice of Medical Assistance Lien, Form 470-3030, to the insurer.  d.  The mailing and deposit in a United States post office or public mailing box of the notice, addressed to the attorney or insurer, is adequate legal notice of the department’s subrogation rights.  75.4(6)  For purposes of this rule, the term “third party” includes an attorney, individual, institution, corporation, or public or private agency which is or may be liable to pay part or all of the medical costs incurred as a result of injury, disease or disability by or on behalf of an applicant for medical assistance or a past or present Medicaid member.  75.4(7)  The department may enforce its lien by a civil action against any liable third party.This rule is intended to implement Iowa Code sections 249A.4, 249A.5, and 249A.6.Related ARC(s): 9696B, 9881B441—75.5(249A)  Determination of countable income and resources for persons in a medical institution.  In determining eligibility for any coverage group under rule 441—75.1(249A), certain factors must be considered differently for persons who reside in a medical institution. They are:  75.5(1)  Determining income from property.  a.    Nontrust property.  Where there is nontrust property, unless the document providing income specifies differently, income paid in the name of one person shall be available only to that person. If payment of income is in the name of two persons, one-half is attributed to each. If payment is in the name of several persons, including a Medicaid client, a client’s spouse, or both, the income shall be considered in proportion to the Medicaid client’s or spouse’s interest. If payment is made jointly to both spouses and no interest is specified, one-half of the couple’s joint interest shall be considered available for each spouse. If the client or the client’s spouse can establish different ownership by a preponderance of evidence, the income shall be divided in proportion to the ownership.  b.    Trust property.  Where there is trust property, the payment of income shall be considered available as provided in the trust. In the absence of specific provisions in the trust, the income shall be considered as stated above for nontrust property.  75.5(2)  Division of income between married people for SSI-related coverage groups.  a.    Institutionalized spouse and community spouse.  If there is a community spouse, only the institutionalized person’s income shall be considered in determining eligibility for the institutionalized spouse.  b.    Spouses institutionalized and living together.  Partners in a marriage who are residing in the same room in a medical institution shall be treated as a couple until the first day of the seventh calendar month that they continuously reside in the facility. The couple may continue to be considered as a couple for medical assistance effective the first day of the seventh calendar month of continuous residency if one partner would be ineligible for medical assistance or receive reduced benefits by considering them separate individuals or if they choose to be considered together. When spouses are treated as a couple, the combined income of the couple shall not exceed twice the amount of the income limit established in subrule 75.1(7). Persons treated together as a couple for income must be treated together for resources and persons treated individually for income must be treated individually for resources.Spouses residing in the same room in a medical institution may be treated as individuals effective the first day of the seventh calendar month. The income of each spouse shall not exceed the income limit established in subrule 75.1(7).  c.    Spouses institutionalized and living apart.  Partners in a marriage who are both institutionalized, although not residing in the same room of the institution, shall be treated as individuals effective the month after the month the partners cease living together. Their income shall be treated separately for eligibility. If they live in the same facility after six months of continuous residence, they may be considered as a couple for medical assistance effective the first day of the seventh calendar month of continuous residency if one partner would be ineligible for medical assistance or receive reduced benefits by considering them separate individuals or if they choose to be considered together.In the month of entry into a medical institution, income shall not exceed the amount of the income limit established in subrule 75.1(7).  75.5(3)  Attribution of resources to institutionalized spouse and community spouse. The department shall determine the attribution of a couple’s resources to the institutionalized spouse and to the community spouse when the institutionalized spouse is expected to remain in a medical institution at least 30 consecutive days on or after September 30, 1989, at the beginning of the first continuous period of institutionalization.  a.    When determined.  The department shall determine the attribution of resources between spouses at the earlier of the following:  (1)  When either spouse requests that the department determine the attribution of resources at the beginning of the person’s continuous stay in a medical facility prior to an application for Medicaid benefits. This request must be accompanied by Form 470-2577, Resources Upon Entering a Medical Facility, and necessary documentation.  (2)  When the institutionalized spouse or someone acting on that person’s behalf applies for Medicaid benefits. If the application is not made in the month of entry, the applicant shall also complete Form 470-2577 and provide necessary documentation.  b.    Information required.  The couple must provide the social security number of the community spouse. The attribution process shall include a match of the Internal Revenue Service data for both the institutionalized and community spouses.  c.    Resources considered.  The resources attributed shall include resources owned by both the community spouse and institutionalized spouse except for the following resources:  (1)  The home in which the spouse or relatives as defined in 441—paragraph 41.22(3)“a” live (including the land that appertains to the home).  (2)  Household goods, personal effects, and one automobile.  (3)  The value of any burial spaces held for the purpose of providing a place for the burial of either spouse or any other member of the immediate family.  (4)  Other property essential to the means of self-support of either spouse as to warrant its exclusion under the SSI program.  (5)  Resources of a blind or disabled person who has a plan for achieving self-support as determined by division of vocational rehabilitation or the department of human services.  (6)  For natives of Alaska, shares of stock held in a regional or a village corporation, during the period of 20 years in which the stock is inalienable, as provided in Section 7(h) and Section 8(c) of the Alaska Native Claims Settlement Act.  (7)  Assistance under the Disaster Relief Act and Emergency Assistance Act or other assistance provided pursuant to federal statute on account of a presidentially declared major disaster and interest earned on these funds for the nine-month period beginning on the date these funds are received or for a longer period where good cause is shown.  (8)  Any amount of underpayment of SSI or social security benefit due either spouse for one or more months prior to the month of receipt. This exclusion shall be limited to the first six months following receipt.  (9)  A life insurance policy(ies) whose total face value is $1500 or less per spouse.  (10)  An amount, not in excess of $1500 for each spouse that is separately identifiable and has been set aside to meet the burial and related expenses of that spouse. The amount of $1500 shall be reduced by an amount equal to the total face value of all insurance policies which are owned by the person or spouse and the total of any amounts in an irrevocable trust or other irrevocable arrangement available to meet the burial and related expenses of that spouse.  (11)  Federal assistance paid for housing occupied by the spouse.  (12)  Assistance from a fund established by a state to aid victims of crime for nine months from receipt when the client demonstrates that the amount was paid as compensation for expenses incurred or losses suffered as a result of a crime.  (13)  Relocation assistance provided by a state or local government to a client comparable to assistance provided under Title II of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 which is subject to the treatment required by Section 216 of the Act.  d.    Method of attribution.  The resources attributed to the institutionalized spouse shall be one-half of the documented resources of both the institutionalized spouse and the community spouse as of the first moment of the first day of the month of the spouse’s first entry to a medical facility. However, if one-half of the resources is less than $24,000, then $24,000 shall be protected for the community spouse. Also, when one-half of the resources attributed to the community spouse exceeds the maximum amount allowed as a community spouse resource allowance by Section 1924(f)(2)(A)(i) of the Social Security Act (42 U.S.C. § 1396r-5(f)(2)(A)(i)), the amount over the maximum shall be attributed to the institutionalized spouse. (The maximum limit is indexed annually according to the consumer price index.)If the institutionalized spouse has transferred resources to the community spouse under a court order for the support of the community spouse, the amount transferred shall be the amount attributed to the community spouse if it exceeds the specified limits above.  e.    Notice and appeal rights.  The department shall provide each spouse a notice of the attribution results. The notice shall state that either spouse has a right to appeal the attribution if the spouse believes:  (1)  That the attribution is incorrect, or  (2)  That the amount of income generated by the resources attributed to the community spouse is inadequate to raise the community spouse’s income to the minimum monthly maintenance allowance.If an attribution has not previously been appealed, either spouse may appeal the attribution upon the denial of an application for Medicaid benefits based on the attribution.  f.    Appeals.  Hearings on attribution decisions shall be governed by procedures in 441—Chapter 7. If the hearing establishes that the community spouse’s resource allowance is inadequate to raise the community spouse’s income to the minimum monthly maintenance allowance, there shall be substituted an amount adequate to provide the minimum monthly maintenance needs allowance.  (1)  To establish that the resource allowance is inadequate and receive a substituted allowance, the applicant must provide verification of all the income of the community spouse. For an applicant who became an institutionalized spouse on or after February 8, 2006, all income of the institutionalized spouse that could be made available to the community spouse pursuant to 75.16(2)“d” shall be treated as countable income of the community spouse when the attribution decision was made on or after February 8, 2006.  (2)  The amount of resources adequate to provide the community spouse minimum maintenance needs allowance shall be based on the cost of a single premium lifetime annuity with monthly payments equal to the difference between the monthly maintenance needs allowance and other countable income not generated by either spouse’s countable resources.  (3)  The resources necessary to provide the minimum maintenance needs allowance shall be based on the maintenance needs allowance as provided by these rules at the time of the filing of the appeal.  (4)  To receive the substituted allowance, the applicant shall be required to obtain one estimate of the cost of the annuity.  (5)  The estimated cost of an annuity shall be substituted for the amount of resources attributed to the community spouse when the amount of resources previously determined is less than the estimated cost of an annuity. If the amount of resources previously attributed for the community spouse is greater than the estimated cost of an annuity, there shall be no substitution for the cost of the annuity, and the attribution will remain as previously determined.  (6)  The applicant shall not be required to purchase this annuity as a condition of Medicaid eligibility.  (7)  If the appellant provides a statement from an insurance company that it will not provide an estimate due to the potential annuitant’s age, the amount to be set aside shall be determined using the following calculation: The difference between the community spouse’s gross monthly income not generated by countable resources (times 12) and the minimum monthly maintenance needs allowance (times 12) shall be multiplied by the annuity factor for the age of the community spouse in the Table for an Annuity for Life published at the end of Iowa Code chapter 450. This amount shall be substituted for the amount of resources attributed to the community spouse pursuant to subparagraph 75.5(3)“f”(5).  75.5(4)  Consideration of resources of married people.  a.  One spouse in a medical facility who entered the facility on or after September 30, 1989.  (1)  Initial month. When the institutionalized spouse is expected to stay in a medical facility less than 30 consecutive days, the resources of both spouses shall be considered in determining initial Medicaid eligibility.When the institutionalized spouse is expected to be in a medical facility 30 consecutive days or more, only the resources not attributed to the community spouse according to subrule 75.5(3) shall be considered in determining initial eligibility for the institutionalized spouse.The amount of resources counted for eligibility for the institutionalized spouse shall be the difference between the couple’s total resources at the time of application and the amount attributed to the community spouse under this rule.  (2)  Ongoing eligibility. After the month in which the institutionalized spouse is determined eligible, no resources of the community spouse shall be deemed available to the institutionalized spouse during the continuous period in which the spouse is in an institution. Resources which are owned wholly or in part by the institutionalized spouse and which are not transferred to the community spouse shall be counted in determining ongoing eligibility. The resources of the institutionalized spouse shall not count for ongoing eligibility to the extent that the institutionalized spouse intends to transfer and does transfer the resources to the community spouse within 90 days unless unable to effect the transfer.  (3)  Exception based on estrangement. When it is established by a disinterested third-party source that the institutionalized spouse is estranged from the community spouse, Medicaid eligibility will not be denied on the basis of resources when the applicant can demonstrate hardship.The applicant can demonstrate hardship when the applicant is unable to obtain information about the community spouse’s resources after exploring all legal means.The applicant can also demonstrate hardship when resources attributed from the community spouse cause the applicant to be ineligible, but the applicant is unable to access these resources after exhausting legal means.  (4)  Exception based on assignment of support rights. The institutionalized spouse shall not be ineligible by attribution of resources that are not actually available when:
    1. The institutionalized spouse has assigned to the state any rights to support from the community spouse, or
    2. The institutionalized spouse lacks the ability to execute an assignment due to physical or mental impairment, but the state has the right to bring a support proceeding against a community spouse without an assignment.
      b.  One spouse in a medical institution prior to September 30, 1989. When one spouse is in the medical institution prior to September 30, 1989, only the resources of the institutionalized spouse shall count for eligibility according to SSI policies the month after the month of entry. In the month of entry, the resources of both spouses are countable toward the couple resource limit.  c.  Spouses institutionalized and living together. The combined resources of both partners in a marriage who are residing in the same room in a medical institution shall be subject to the resource limit for a married couple until the first of the seventh calendar month that they continuously reside in the facility. The couple may continue to be considered as a couple for medical assistance effective with the seventh month if one partner would be ineligible for medical assistance or would receive reduced benefits by considering them separately or if they choose to be considered together. Persons treated together as a couple for resources must be treated together for income and persons treated individually for resources must be treated individually for income. Effective the first of the seventh calendar month of continuous residence, they may be treated as individuals, with the resource limit for each spouse the limit for a single person.  d.  Spouses institutionalized and living apart. Partners in a marriage who are both institutionalized, although not residing in the same room of the institution, shall be treated as individuals effective the month after the month the partners cease living together. If they live in the same facility after six months of continuous residence, they may be considered as a couple for medical assistance effective the first day of the seventh calendar month of continuous residency if one partner would be ineligible for medical assistance or would receive reduced benefits by considering them separately or if they choose to be considered together.In the month of entry into a medical institution, all resources of both spouses shall be combined and shall be subject to the resource limit for a married couple.
      75.5(5)  Consideration of resources for persons in a medical institution who have purchased and used a qualified or approved long-term care insurance policy pursuant to department of commerce, division of insurance, rules in 191—Chapter 39 or 72.  a.    Eligibility.  A person may be eligible for medical assistance under this subrule if:  (1)  The person is the beneficiary of a qualified long-term care insurance policy or is enrolled in a prepaid health care delivery plan that provides long-term care services pursuant to 191—Chapter 39 or 72; and  (2)  The person is eligible for medical assistance under 75.1(6), 75.1(7), or 75.1(18) except for excess resources; and  (3)  The excess resources causing ineligibility under the listed coverage groups do not exceed the “asset adjustment” provided in this subrule.  b.    Definition.  “Asset adjustment” shall mean a $1 disregard of resources for each $1 that has been paid out under the person’s qualified or approved long-term care insurance policy.  c.    Estate recovery.  An amount equal to the benefits paid out under a member’s qualified or approved long-term care insurance policy will be exempt from recovery from the estate of the member or the member’s spouse for payments made by the medical assistance program on behalf of the member.This rule is intended to implement Iowa Code sections 249A.3, 249A.4, and 249A.35 and chapter 514H.
    Related ARC(s): 8443B441—75.6(249A)  Entrance fee for continuing care retirement community or life care community.  When an individual resides in a continuing care retirement community or life care community that collects an entrance fee on admission, the entrance fee paid shall be considered a resource available to the individual for purposes of determining the individual’s Medicaid eligibility and the amount of benefits to the extent that:
    1. The individual has the ability to use the entrance fee, or the contract between the individual and the community provides that the entrance fee may be used to pay for care should the individual’s other resources or income be insufficient to pay for such care;
    2. The individual is eligible for a refund of any remaining entrance fee when the individual dies or when the individual terminates the community contract and leaves the community; and
    3. The entrance fee does not confer an ownership interest in the community.
    This rule is intended to implement Iowa Code section 249A.4.
    441—75.7(249A)  Furnishing of social security number.    75.7(1)  As a condition of eligibility, except as provided by subrule 75.7(2), all social security numbers issued to each individual (including children) for whom Medicaid is sought must be furnished to the department.  75.7(2)  The requirement of subrule 75.7(1) does not apply to an individual who:  a.  Is not eligible to receive a social security number;  b.  Does not have a social security number and may only be issued a social security number for a valid nonwork reason in accordance with 20 CFR § 422.104; or  c.  Refuses to obtain a social security number because of a well-established religious objection. For this purpose, a well-established religious objection means that the individual:  (1)  Is a member of a recognized religious sect or division of the sect; and  (2)  Adheres to the tenets or teachings of the sect or division of the sect and for that reason is conscientiously opposed to applying for or using a national identification number.  75.7(3)  If a social security number has not been issued or is not known, the individual seeking Medicaid must cooperate with the department in applying for a social security number with the Social Security Administration or in requesting the Social Security Administration to furnish the number.Related ARC(s): 1134C441—75.8(249A)  Medical assistance corrective payments.  If a decision by the department or the Social Security Administration following an appeal on a denied application for any of the categories of medical assistance eligibility set forth in rule 441—75.1(249A) is favorable to the claimant, reimbursement will be made to the claimant for any medical bills paid by the claimant during the period between the date of the denial on the initial application and the date regular medical assistance coverage began when the bills were for medical services rendered in the period now determined to be an eligible period based on the following conditions:  75.8(1)  These bills must be for services covered by the medical assistance program as set forth in 441—Chapter 78.  75.8(2)  Reimbursement will be based on Medicaid rates for services in effect at the time the services were provided.  75.8(3)  If a county relief agency has paid medical bills on the recipient’s behalf and has not received reimbursement through assignment as set forth in 441—Chapter 80, the department will reimburse the county relief agency directly on the same basis as if the reimbursement was made to the recipient.  75.8(4)  Recipients and county relief agencies shall file claims for payment under this subrule by submitting Form 470-2224, Verification of Paid Medical Bills, to the department. A supply of these forms is available from the county office. All requests for reimbursement shall be acted upon within 60 days of receipt of all Forms 470-2224 in the county office.  75.8(5)  Any adverse action taken by the department with respect to an application for reimbursement is appealable under 441—Chapter 7.This rule is intended to implement Iowa Code section 249A.4.441—75.9(249A)  Treatment of Medicaid qualifying trusts.    75.9(1)  A Medicaid qualifying trust is a trust or similar legal device established, on or before August 10, 1993, other than by will by a person or that person’s spouse under which the person may be the beneficiary of payments from the trust and the distribution of these payments is determined by one or more trustees who are permitted to exercise any discretion with respect to the distribution to the person. Trusts or initial trust decrees established prior to April 7, 1986, solely for the benefit of a mentally retarded person who resides in an intermediate care facility for the mentally retarded, are exempt.  75.9(2)  The amount of income and principal from a Medicaid qualifying trust that shall be considered available shall be the maximum amount that may be permitted under the terms of the trust assuming the full exercise of discretion by the trustee or trustees for the distribution of the funds.  a.  Trust income considered available shall be counted as income.  b.  Trust principal (including accumulated income) considered available shall be counted as a resource, except where the trust explicitly limits the amount of principal that can be made available on an annual or less frequent basis. Where the trust limits the amount, the principal considered available over any particular period of time shall be counted as income for that period of time.  c.  To the extent that the trust principal and income is available only for medical care, this principal or income shall not be used to determine eligibility. To the extent that the trust is restricted to medical expenses, it shall be used as a third party resource.This rule is intended to implement Iowa Code section 249A.4.441—75.10(249A)  Residency requirements.  Residency in Iowa is a condition of eligibility for medical assistance.  75.10(1)    Definitions.    a.    Institutions.  For purposes of this rule, “institution” means an “institution” or a “medical institution” as those terms are defined in 42 CFR § 435.1010 as amended to July 13, 2007. For purposes of state placement, “institution” also includes foster care homes licensed as set forth in 45 CFR § 1355.20 as amended to January 6, 2012, and providing food, shelter and supportive services to one or more persons unrelated to the proprietor.  b.    Incapable of expressing intent regarding residency.  For purposes of this rule, an individual is considered to be “incapable of indicating intent regarding residency” if the individual:
    1. Has an IQ of 49 or less or has a mental age of seven or less;
    2. Has been judged legally incompetent; or
    3. Has been determined to be incapable of indicating intent regarding residency by a physician, psychologist or other person licensed by the state in the field of intellectual disability.
      75.10(2)    Determination of residency.  State residency is determined according to the following criteria. If more than one criterion applies, the applicable criterion listed first determines the individual’s residency:  a.  Cases of disputed residency. If two or more states do not agree on an individual’s state of residence, the state where the individual is physically located is the state of residence.  b.  Temporary absence from state of residence. An individual who was a resident of a state pursuant to the other criteria of this rule, who is temporarily absent from that state, and who intends to return to that state when the purpose of the absence has been accomplished remains a resident of that state during the absence, unless another state has determined that the person is a resident there for Medicaid purposes.  c.  Individuals placed by a state in an out-of-state institution. If any agency of a state, including an entity recognized under state law as being under contract with the state for such purposes, arranges for an individual to be placed in an institution located in another state, the state arranging or actually making the placement is considered the individual’s state of residence during that placement.  (1)  Any action beyond providing information to the individual and the individual’s family constitutes arranging or making a placement. However, the following actions do not constitute arranging or making a placement:
    1. Providing basic information to individuals about another state’s Medicaid program and information about the availability of health care services and facilities in another state.
    2. Assisting an individual in locating an institution in another state, provided the individual is not incapable of indicating intent regarding residency and independently decides to move.
      (2)  When a competent individual leaves an out-of-state institution in which the individual was placed by a state, that individual’s state of residence is the state where the individual is physically located.
      d.  Individuals receiving a state supplementary assistance payment. Individuals who are receiving a state supplementary assistance payment pursuant to 42 U.S.C. § 1382e (including payments from Iowa pursuant to rules 441—50.1(249) through 441—54.8(249), 441—81.23(249A), 441—82.19(249A), 441—85.47(249A), or 441—177.1(249) through 441—177.11(249)) are considered to be residents of the state paying the supplementary assistance.  e.  Individuals receiving Title IV-E payments. Individuals who are receiving federal foster care or adoption assistance payments for a child under Title IV-E of the Social Security Act are considered to be residents of the state where the child lives.  f.  Individuals aged 21 and over who are residing in an institution and who are capable of indicating intent regarding residency. For an individual aged 21 or over who is residing in an institution and who is not incapable of indicating intent regarding residency, the state of residence is the state where the individual is living and intends to reside.  g.  Individuals aged 21 and over who are residing in an institution and who became incapable of indicating intent regarding residency before the age of 21. For an individual aged 21 or over who is residing in an institution and who became incapable of indicating intent regarding residency before the age of 21, the state of residence is:  (1)  That of the parent applying for Medicaid on the individual’s behalf if the parents reside in separate states (if a legal guardian has been appointed and parental rights are terminated, the state of residence of the guardian is used instead of that of the parent);  (2)  The parent’s or legal guardian’s state of residence at the time of placement (if a legal guardian has been appointed and parental rights are terminated, the state of residence of the guardian is used instead of that of the parent);  (3)  The current state of residence of the parent or legal guardian who files the application if the individual is residing in an institution in that state (if a legal guardian has been appointed and parental rights are terminated, the state of residence of the guardian is used instead of that of the parent); or  (4)  The state of residence of the individual or party who files an application if the individual has been abandoned by the individual’s parent(s), does not have a legal guardian, and is residing in an institution in that state.  h.  Individuals aged 21 and over who are residing in an institution and who became incapable of indicating intent regarding residency at or after the age of 21. For an individual aged 21 or over who is residing in an institution and who became incapable of indicating intent regarding residency at or after the age of 21, the state of residence is the state in which the individual is physically present.  i.  Individuals aged 21 and over who are not residing in an institution and who are incapable of indicating intent regarding residency. For an individual aged 21 or over who is not residing in an institution and who is incapable of indicating intent regarding residency, the state of residence is the state where the individual is living.  j.  Individuals aged 21 and over who are not residing in an institution and who are capable of indicating intent regarding residency. For an individual aged 21 or over who is not residing in an institution and who is not incapable of indicating intent regarding residency, the state of residence is the state where the individual is living and either:  (1)  Intends to reside, with or without a fixed address; or  (2)  Entered with a job commitment or to seek employment, whether or not currently employed.  k.  Individuals under the age of 21 who are residing in an institution and who are not married or emancipated. For an individual under the age of 21 who is residing in an institution and who is neither married nor emancipated, the state of residence is:  (1)  The parent’s or legal guardian’s state of residence at the time of placement (if a legal guardian has been appointed and parental rights are terminated, the state of residence of the guardian is used instead of that of the parent);  (2)  The current state of residence of the parent or legal guardian who files the application if the individual is residing in an institution in that state (if a legal guardian has been appointed and parental rights are terminated, the state of residence of the guardian is used instead of that of the parent); or  (3)  The state of residence of the individual or party who files an application if the individual has been abandoned by the individual’s parent(s), does not have a legal guardian, and is residing in an institution in that state.  l.  Individuals under the age of 21 who are capable of indicating intent regarding residency and who are married or emancipated. For an individual under the age of 21 who is not incapable of indicating intent regarding residency and who is married or emancipated from the individual’s parent, the state of residence is determined in accordance with paragraph 75.10(2)“j.”  m.  Other individuals under the age of 21. For an individual under the age of 21 who is not described in paragraph 75.10(2)“k” or “l,” the state of residence is:  (1)  The state where the individual resides, with or without a fixed address; or  (2)  The state of residency of the parent or caretaker, determined in accordance with paragraph 75.10(2)“j,” with whom the individual resides.
    This rule is intended to implement Iowa Code section 249A.3.
    Related ARC(s): 1134C441—75.11(249A)  Citizenship or alienage requirements.    75.11(1)    Definitions.  
    "Care and services necessary for the treatment of an emergency medical condition" means services provided in a hospital, clinic, office or other facility that is equipped to furnish the required care for an emergency medical condition, provided the care and services are not related to an organ transplant procedure furnished on or after August 10, 1993. Payment for emergency medical services shall be limited to the day treatment is initiated for the emergency medical condition and the following two days.
    "Emergency medical condition" means a medical condition of sudden onset (including labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in one or more of the following:
    1. Placing the patient’s health in serious jeopardy.
    2. Serious impairment to bodily functions.
    3. Serious dysfunction of any bodily organ or part.
    "Federal means-tested program" means all federal programs that are means-tested with the exception of:
    1. Medical assistance for care and services necessary for the treatment of an emergency medical condition not related to an organ transplant procedure furnished on or after August 10, 1993.
    2. Short-term, non-cash, in-kind emergency disaster relief.
    3. Assistance or benefits under the National School Lunch Act.
    4. Assistance or benefits under the Child Nutrition Act of 1966.
    5. Public health assistance (not including any assistance under Title XIX of the Social Security Act) for immunizations with respect to immunizable diseases and for testing and treatment of symptoms of communicable diseases whether or not the symptoms are caused by a communicable disease.
    6. Payments of foster care and adoption assistance under Parts B and E of Title IV of the Social Security Act for a parent or a child who would, in the absence of numbered paragraph “1,” be eligible to have payments made on the child’s behalf under such part, but only if the foster or adoptive parent (or parents) of the child is a qualified alien (as defined in Section 431).
    7. Programs, services, or assistance (such as soup kitchens, crisis counseling and intervention, and short-term shelter) specified by the attorney general of the United States in the attorney general’s sole and unreviewable discretion after consultation with appropriate federal agencies and departments, that:
    8. Deliver in-kind services at the community level, including through public or private nonprofit agencies;
    9. Do not condition the provision of assistance, the amount of assistance provided, or the cost of assistance provided on the individual recipient’s income or resources; and
    10. Are necessary for the protection of life or safety.
    11. Programs of student assistance under Titles IV, V, IX, and X of the Higher Education Act of 1965, and Titles III, VII, and VIII of the Public Health Services Act.
    12. Means-tested programs under the Elementary and Secondary Education Act of 1965.
    13. Benefits under the Head Start Act.
    14. Benefits funded through an employment and training program of the U.S. Department of Labor.
    "Qualified alien" means an alien:
    1. Who is lawfully admitted for permanent residence in the United States under the Immigration and Nationality Act (INA);
    2. Who is granted asylum in the United States under Section 208 of the INA;
    3. Who is a refugee admitted to the United States under Section 207 of the INA;
    4. Who is paroled into the United States under Section 212(d)(5) of the INA for a period of at least one year;
    5. Whose deportation from the United States is withheld under Section 243(h) of the INA as in effect before April 1, 1997, or under Section 241(b)(3) of the INA as amended to December 20, 2010;
    6. Who is granted conditional entry to the United States pursuant to Section 203(a)(7) of the INA as in effect before April 1, 1980;
    7. Who is an Amerasian admitted to the United States as described in 8 U.S.C. Section 1612(b)(2)(A)(i)(V);
    8. Who is a Cuban/Haitian entrant to the United States as described in 8 U.S.C. Section 1641(b)(7);
    9. Who is a battered alien as described in 8 U.S.C. Section 1641(c);
    10. Who is certified as a victim of trafficking as described in Section 107(b)(1)(A) of Public Law 106-386 as amended to December 20, 2010;
    11. Who is an American Indian born in Canada to whom Section 289 of the INA applies or is a member of a federally recognized Indian Tribe as defined in 25 U.S.C. Section 450b(e); or
    12. Who is under the age of 21 and is lawfully residing in the United States as allowed by 42 U.S.C. Section 1396b(v)(4)(A)(ii).
    "Qualifying quarters" includes all of the qualifying quarters of coverage as defined under Title II of the Social Security Act worked by a parent of an alien while the alien was under age 18 and all of the qualifying quarters worked by a spouse of the alien during their marriage if the alien remains married to the spouse or the spouse is deceased. No qualifying quarter of coverage that is creditable under Title II of the Social Security Act for any period beginning after December 31, 1996, may be credited to an alien if the parent or spouse of the alien received any federal means-tested public benefit during the period for which the qualifying quarter is so credited.
      75.11(2)    Citizenship and alienage.    a.  To be eligible for Medicaid, a person must be one of the following:  (1)  A citizen or national of the United States.  (2)  A qualified alien residing in the United States before August 22, 1996.  (3)  A qualified alien under the age of 21.  (4)  A refugee admitted to the United States under Section 207 of the Immigration and Nationality Act (INA).  (5)  An alien who has been granted asylum under Section 208 of the INA.  (6)  An alien whose deportation is withheld under Section 243(h) or Section 241(b)(3) of the INA.  (7)  A qualified alien veteran who has an honorable discharge that is not due to alienage.  (8)  A qualified alien who is on active duty in the Armed Forces of the United States other than active duty for training.  (9)  A qualified alien who is the spouse or unmarried dependent child of a qualified alien described in subparagraph (7) or (8), including a surviving spouse who has not remarried.  (10)  A qualified alien who has resided in the United States for a period of at least five years.  (11)  An Amerasian admitted as described in 8 U.S.C. Section 1612(b)(2)(A)(i)(V).  (12)  A Cuban/Haitian entrant as described in 8 U.S.C. Section 1641(b)(7).  (13)  A certified victim of trafficking as described in Section 107(b)(1)(A) of Public Law 106-386 as amended to December 20, 2010.  (14)  An American Indian born in Canada to whom Section 289 of the INA applies or who is a member of a federally recognized Indian Tribe as defined in 25 U.S.C. Section 450b(e).  (15)  An Iraqi or Afghan immigrant treated as a refugee pursuant to Section 1244(g) of Public Law 110-181 as amended to December 20, 2010, or to Section 602(b)(8) of Public Law 111-8 as amended to December 20, 2010.  b.  As a condition of eligibility, each member shall complete and sign Form 470-2549, Statement of Citizenship Status, attesting to the member’s citizenship or alien status. When the member is incompetent or deceased, the form shall be signed by someone acting responsibly on the member’s behalf. An adult shall sign the form for dependent children.  (1)  As a condition of eligibility, all applicants for Medicaid shall attest to their citizenship or alien status by signing the application form which contains the same declaration.  (2)  As a condition of continued eligibility, SSI-related Medicaid members not actually receiving SSI who have been continuous members since August 1, 1988, shall attest to their citizenship or alien status by signing the application form which contains a similar declaration at time of review.  (3)  An attestation of citizenship or alien status completed on any one of the following forms shall meet the requirements of subrule 75.11(2) for children under the age of 19 who are otherwise eligible pursuant to 441—subrule 76.1(8):
    1. Application for Food Assistance, Form 470-0306 or 470-0307 (Spanish);
    2. Health and Financial Support Application, Form 470-0462 or 470-0462(S); or
    3. Review/Recertification Eligibility Document, Form 470-2881, 470-2881(S), 470-2881(M), or 470-2881(MS).
      c.  Except as provided in paragraph “f,” applicants or members for whom an attestation of United States citizenship has been made pursuant to paragraph “b” shall present satisfactory documentation of citizenship or nationality as defined in paragraph “d,” “e,” or “i.” A reference to a form in paragraph “d” or “e” includes any successor form. An applicant or member shall have a reasonable period to obtain and provide required documentation of citizenship or nationality.  (1)  For the purposes of this requirement, the “reasonable period” begins on the date a written request for documentation or a notice pursuant to subparagraph 75.11(2)“i”(2) is issued to an applicant or member, whichever is later, and continues for 90 days.  (2)  Medicaid shall be approved for new applicants and continue for members not previously required to provide documentation of citizenship or nationality until the end of the reasonable period to obtain and provide required documentation of citizenship or nationality. However, the receipt of Medicaid or HAWK-I benefits pending documentation of citizenship or nationality is limited to one reasonable period of up to 90 days under either program for each individual. An applicant or member who has already received benefits during any portion of a reasonable period shall not be granted coverage for a second reasonable period except as required to protect the confidentiality of an individual who received only limited Medicaid benefits provided pursuant to subrule 75.1(41) during the first period.  (3)  Retroactive eligibility pursuant to 441—subrule 76.13(3) is available only after documentation of citizenship or nationality has been provided pursuant to paragraph 75.11(2)“d,” “e,” or “i.” The retroactive months are outside the “reasonable period” during which Medicaid coverage may be provided without required documentation of citizenship or nationality.  d.  Any one of the following documents shall be accepted as satisfactory documentation of citizenship or nationality:  (1)  A United States passport.  (2)  Form N-550 or N-570 (Certificate of Naturalization) issued by the U.S. Citizenship and Immigration Services.  (3)  Form N-560 or N-561 (Certificate of United States Citizenship) issued by the U.S. Citizenship and Immigration Services.  (4)  A valid state-issued driver’s license or other identity document described in Section 274A(b)(1)(D) of the United States Immigration and Nationality Act, but only if the state issuing the license or document either:
    1. Requires proof of United States citizenship before issuance of the license or document; or
    2. Obtains a social security number from the applicant and verifies before certification that the number is valid and is assigned to the applicant who is a citizen.
      (5)  Documentation issued by a federally recognized Indian Tribe showing membership or enrollment in or affiliation with that Tribe.  (6)  Another document that provides proof of United States citizenship or nationality and provides a reliable means of documentation of personal identity, as the Secretary of the U.S. Department of Health and Human Services may specify by regulation pursuant to 42 U.S.C. Section 1396b(x)(3)(B)(v).
      e.  Satisfactory documentation of citizenship or nationality may also be demonstrated by the combination of:  (1)  Any identity document described in Section 274A(b)(1)(D) of the United States Immigration and Nationality Act or any other documentation of personal identity that provides a reliable means of identification, as the secretary of the U.S. Department of Health and Human Services finds by regulation pursuant to 42 U.S.C. Section 1396b(x)(3)(D)(ii), and  (2)  Any one of the following:
    1. A certificate of birth in the United States.
    2. Form FS-545 or Form DS-1350 (Certification of Birth Abroad) issued by the U.S. Citizenship and Immigration Services.
    3. Form I-97 (United States Citizen Identification Card) issued by the U.S. Citizenship and Immigration Services.
    4. Form FS-240 (Report of Birth Abroad of a Citizen of the United States) issued by the U.S. Citizenship and Immigration Services.
    5. Another document that provides proof of United States citizenship or nationality, as the secretary of the U.S. Department of Health and Human Services may specify pursuant to 42 U.S.C. Section 1396b(x)(3)(C)(v).
      f.  A person for whom an attestation of United States citizenship has been made pursuant to paragraph “b” is not required to present documentation of citizenship or nationality for Medicaid eligibility if any of the following circumstances apply:  (1)  The person is entitled to or enrolled for benefits under any part of Title XVIII of the federal Social Security Act (Medicare).  (2)  The person is receiving federal social security disability insurance (SSDI) benefits under Title II of the federal Social Security Act, Section 223 or 202, based on disability (as defined in Section 223(d)).  (3)  The person is receiving supplemental security income (SSI) benefits under Title XVI of the federal Social Security Act.  (4)  The person is a child in foster care who is assisted by child welfare services funded under Part B of Title IV of the federal Social Security Act.  (5)  The person is receiving foster care maintenance or adoption assistance payments funded under Part E of Title IV of the federal Social Security Act.  (6)  The person has previously presented satisfactory documentary evidence of citizenship or nationality, as specified by the United States Secretary of Health and Human Services.  (7)  The person is or was eligible for medical assistance pursuant to 42 U.S.C. Section 1396a(e)(4) as the newborn of a Medicaid-eligible mother.  (8)  The person is or was eligible for medical assistance pursuant to 42 U.S.C. Section 1397ll(e) as the newborn of a mother eligible for assistance under a State Children’s Health Insurance Program (SCHIP) pursuant to Title XXI of the Social Security Act.  g.  If no other identity documentation allowed by subparagraph 75.11(2)“e”(1) is available, identity may be documented by affidavit as described in this paragraph. However, affidavits cannot be used to document both identity and citizenship.  (1)  For children under the age of 16, identity may be documented using Form 470-4386 or 470-4386(S), Affidavit of Identity, signed by the child’s parent, guardian, or caretaker relative under penalty of perjury.  (2)  For disabled persons who live in a residential care facility, identity may be documented using Form 470-4386 or 470-4386(S), Affidavit of Identity, signed by a residential care facility director or administrator under penalty of perjury.  h.  If no other documentation that provides proof of United States citizenship or nationality allowed by subparagraph 75.11(2)“e”(2) is available, United States citizenship or nationality may be documented using Form 470-4373 or 470-4373(S), Affidavit of Citizenship. However, affidavits cannot be used to document both identity and citizenship.  (1)  Two affidavits of citizenship are required. The person who signs the affidavit must provide proof of citizenship and identity. A person who is not related to the applicant or member must sign at least one of the affidavits.  (2)  When affidavits of citizenship are used, Form 470-4374 or 470-4374(S), Affidavit Concerning Documentation of Citizenship, or an equivalent affidavit explaining why other evidence of citizenship does not exist or cannot be obtained must also be submitted and must be signed by the applicant or member or by another knowledgeable person (guardian or representative).  i.  In lieu of a document listed in paragraph “d” or “e,” satisfactory documentation of citizenship or nationality may also be presented pursuant to this paragraph.  (1)  Provision of an individual’s name, social security number, and date of birth to the department shall constitute satisfactory documentation of citizenship and identity if submission of the name, social security number, and date of birth to the Social Security Administration produces a response that substantiates the individual’s citizenship.  (2)  If submission of the name, social security number, and date of birth to the Social Security Administration does not produce a response that substantiates the individual’s citizenship, the department shall issue a written notice to the applicant or member giving the applicant or member 90 days to correct any errors in the name, social security number, or date of birth submitted, to correct any errors in the Social Security Administration’s records, or to provide other documentation of citizenship or nationality pursuant to paragraph “d” or “e.”
      75.11(3)    Deeming of sponsor’s income and resources.    a.  When an alien admitted for lawful permanent residence is sponsored by a person who executed an affidavit of support as described in 8 U.S.C. Section 1631(a)(1) on behalf of the alien, the income and resources of the alien shall be deemed to include the income and resources of the sponsor (and of the sponsor’s spouse if living with the sponsor). The amount deemed to the sponsored alien shall be the total gross countable income and resources of the sponsor and the sponsor’s spouse for the FMAP-related or SSI-related coverage group applicable to the sponsored alien’s household as described in 441—75.13(249A) less the following deductions:  (1)  For FMAP-related coverage groups: The same income deductions, diversions, and disregards allowed for stepparent cases as described at 75.57(8)“b” and a $1,500 resource deduction.  (2)  For SSI-related coverage groups: The deductions described at 20 CFR 416.1166a and 416.1204, as amended to April 1, 2010.  b.  An indigent alien is exempt from the deeming of a sponsor’s income and resources for 12 months after indigence is determined. An alien shall be considered indigent if the following are true:  (1)  The alien does not live with the sponsor; and  (2)  The alien’s gross income, including any income actually received from or made available by the sponsor, is less than 100 percent of the federal poverty level for the sponsored alien’s household size.  c.  A battered alien as described in 8 U.S.C. Section 1641(c) is exempt from the deeming of a sponsor’s income and resources for 12 months.  d.  Deeming of the sponsor’s income and resources does not apply when:  (1)  The sponsored alien attains citizenship through naturalization pursuant to Chapter 2 of Title II of the Immigration and Nationality Act.  (2)  The sponsored alien has earned 40 qualifying quarters of coverage as defined in Title II of the Social Security Act or can be credited with 40 qualifying quarters as defined at subrule 75.11(1).  (3)  The sponsored alien or the sponsor dies.  (4)  The sponsored alien is a child under age 21.  (5)  For SSI-related Medicaid, the sponsored alien becomes blind or disabled as defined under Title XVI of the Social Security Act after admission to the United States as a lawful permanent resident.  (6)  For SSI-related Medicaid, three years after the date the sponsored alien was admitted to the United States as a lawful permanent resident.  75.11(4)    Eligibility for payment of emergency medical services.  Aliens who do not meet the provisions of subrule 75.11(2) and who would otherwise qualify except for their alien status are eligible to receive Medicaid for care and services necessary for the treatment of an emergency medical condition as defined in subrule 75.11(1). To qualify for payment under this provision:  a.  The alien must meet all other eligibility criteria, including state residence requirements provided at rules 441—75.10(249A) and 441—75.53(249A), with the exception of rule 441—75.7(249A) and subrules 75.11(2) and 75.11(3).  b.  The medical provider who treated the emergency medical condition or the provider’s designee must submit verification of the existence of the emergency medical condition on either:  (1)  Form 470-4299, Verification of Emergency Health Care Services; or  (2)  A signed statement that contains the same information as requested by Form 470-4299.This rule is intended to implement Iowa Code section 249A.3.
    Related ARC(s): 7932B, 8096B, 8642B, 8786B, 9439B, 3353C, 3549C441—75.12(249A)  Inmates of public institutions.  A person is not eligible for medical assistance for any care or services received while the person is an inmate of a public institution. For the purpose of this rule, “inmate of a public institution” and “public institution” are defined by 42 CFR Section 435.1010 as amended to August 25, 2011.  75.12(1)    Suspension.  Medical assistance shall be suspended, rather than canceled, for the first 12 continuous calendar months that a person is an inmate of a public institution if all of the following conditions are met:  a.  The department is notified of the person’s entry into the public institution through either:  (1)  A monthly report which is provided to the department by the public institution and includes the person’s name, date of birth, and social security number and the date the person entered the institution; or  (2)  Other verified notice received by the department.  b.  The person has entered a public institution on or after January 1, 2012, and has been in the public institution for 30 days or more.  c.  On the date of entry into the public institution, the person was a Medicaid member.  d.  The person is eligible for medical assistance as an individual except for institutional status.  75.12(2)    Coverage during suspension.  While medical assistance is suspended, payment will be made only for services received while the person is not an inmate of a public institution.  75.12(3)    Reinstatement.  The Medicaid case for an inmate who is released from a public institution while Medicaid is suspended will be reopened without an application if both of the following conditions are met:  a.  The department is notified of the person’s release from the public institution through either:  (1)  A monthly report which is provided to the department by the public institution and includes the person’s name, date of birth, and social security number and the date the person was released from the institution; or  (2)  Other verified notice received by the department.  b.  All information available to the department indicates that the person is currently eligible for Iowa Medicaid as an individual.This rule is intended to implement Iowa Code section 249A.3 and 2011 Iowa Acts, Senate File 482, division IX.Related ARC(s): 9957B441—75.13(249A)  Categorical relatedness.    75.13(1)    FMAP-related Medicaid eligibility.  Medicaid eligibility for persons who are under the age of 21, pregnant women, or specified relatives of dependent children who are not blind or disabled shall be determined using the income criteria in effect for the family medical assistance program (FMAP) as provided in subrule 75.1(14) unless otherwise specified. Income shall be considered prospectively.  75.13(2)    SSI-related Medicaid.  Except as otherwise provided in 441—Chapters 75 and 76, persons who are 65 years of age or older, blind, or disabled are eligible for Medicaid only if eligible for the Supplemental Security Income (SSI) program administered by the United States Social Security Administration.  a.    SSI policy reference.  The statutes, regulations, and policy governing eligibility for SSI are found in Title XVI of the Social Security Act (42 U.S.C. Sections 1381 to 1383f), in the federal regulations promulgated pursuant to Title XVI (20 CFR 416.101 to 416.2227), and in Part 5 of the Program Operations Manual System published by the United States Social Security Administration. The Program Operations Manual System is available at Social Security Administration offices in Ames, Burlington, Carroll, Cedar Rapids, Clinton, Council Bluffs, Creston, Davenport, Decorah, Des Moines, Dubuque, Fort Dodge, Iowa City, Marshalltown, Mason City, Oskaloosa, Ottumwa, Sioux City, Spencer, Storm Lake, and Waterloo, or through the Department of Human Services, Division of Financial, Health, and Work Supports, Hoover State Office Building, 1305 East Walnut, Des Moines, Iowa 50319-0114.  b.    Income considered.  For SSI-related Medicaid eligibility purposes, income shall be considered prospectively.  c.    Trust contributions.  Income that a person contributes to a trust as specified at 75.24(3)“b” shall not be considered for purposes of determining eligibility for SSI-related Medicaid.  d.    Conditional eligibility.  For purposes of determining eligibility for SSI-related Medicaid, the SSI conditional eligibility process, by which a client may receive SSI benefits while attempting to sell excess resources, found at 20 CFR 416.1240 to 416.1245, is not considered an eligibility methodology.  e.    Valuation of life estates and remainder interests.  In the absence of other evidence, the value of a life estate or remainder interest in property shall be determined using the following table by multiplying the fair market value of the entire underlying property (including all life estates and all remainder interests) by the life estate or remainder interest decimal corresponding to the age of the life estate holder or other person whose life controls the life estate.If a Medicaid applicant or recipient disputes the value determined using the following table, the applicant or recipient may submit other evidence and the value of the life estate or remainder interest shall be determined based on the preponderance of all the evidence submitted to or obtained by the department, including the value given by the following table.AgeLifeEstateRemainderAgeLifeEstateRemainderAgeLifeEstateRemainder0.97188.0281237.93026.0697474.53862.461381.98988.0101238.92567.0743375.52149.478512.99017.0098339.92083.0791776.51441.495593.99008.0099240.91571.0842977.48742.512584.98981.0101941.91030.0897078.47049.529515.98938.0106242.90457.0954379.45357.546436.98884.0111643.89855.1014580.43569.563417.98822.0117844.89221.1077981.41967.580338.98748.0125245.88558.1144282.40295.597059.98663.0133746.87863.1213783.38642.6135810.98565.0143547.87137.1286384.36998.6300211.98453.0154748.86374.1362685.35359.6464112.98329.0167149.85578.1442286.33764.6623613.98198.0180250.84743.1525787.32262.6773814.98066.0193451.83674.1612688.30859.6914115.97937.0206352.82969.1703189.29526.7047416.97815.0218553.82028.1797290.28221.7177917.97700.0230054.81054.1894691.26955.7304518.97590.0241055.80046.1995492.25771.7422919.97480.0252056.79006.2099493.24692.7530820.97365.0263557.77931.2206994.23728.7627221.97245.0275558.76822.2317895.22887.7711322.97120.0288059.75675.2432596.22181.7781923.96986.0301460.74491.2550997.21550.7845024.96841.0315961.73267.2673398.21000.7900025.96678.0332262.72002.2799899.20486.7951426.96495.0350563.70696.29304100.19975.8002527.96290.0371064.69352.30648101.19532.8046828.96062.0393865.67970.32030102.19054.8094629.95813.0418766.66551.33449103.18437.8156330.95543.0445767.65098.343902104.17856.8214431.95254.0474668.63610.363690105.16962.8303832.94942.0505869.62086.37914106.15488.8451233.94608.0539270.60522.39478107.13409.8659134.94250.0575071.58914.41086108.10068.8993235.93868.0613272.57261.42739109.04545.9545536.93460.0654073.55571.44429  75.13(3)    Resource eligibility for SSI-related Medicaid for children.  Resources of all household members shall be disregarded when determining eligibility for children under any SSI-related coverage group except for those groups at subrules 75.1(3), 75.1(4), 75.1(6), 75.1(9), 75.1(10), 75.1(12), 75.1(13), 75.1(23), 75.1(25), 75.1(29), 75.1(33), 75.1(34), 75.1(36), 75.1(37), and 75.1(38).This rule is intended to implement Iowa Code section 249A.3.441—75.14(249A)  Establishing paternity and obtaining support.    75.14(1)  As a condition of eligibility, adult Medicaid applicants and members in households with an absent parent shall cooperate in obtaining medical support for themselves and for any other person in the household for whom Medicaid is requested and for whom the applicant or member can legally assign rights for medical support, except when the applicant or member has good cause for refusal to cooperate as defined in subrule 75.14(8).  a.  The adult applicant or member shall cooperate in the following:  (1)  Identifying and locating the parent of the child for whom Medicaid is requested.  (2)  Establishing the paternity of a child born out of wedlock for whom Medicaid is requested.  (3)  Obtaining medical support and payments for medical care for the applicant or member and for a child for whom Medicaid is requested.  (4)  Rescinded IAB 2/3/93, effective 4/1/93.  b.  Cooperation is defined as including the following actions by the adult applicant or member upon request:  (1)  Appearing at the income maintenance unit or the child support recovery unit to provide verbal or written information or documentary evidence known to, possessed by or reasonably obtainable by the applicant or member that is relevant to achieving the objectives of the child support recovery program.  (2)  Appearing as a witness at judicial or other hearings or proceedings.  (3)  Providing information, or attesting to the lack of information, under penalty of perjury.  c.  Upon request, the adult applicant or member shall cooperate with the department in supplying information with respect to the absent parent, the receipt of medical support or payments for medical care, and the establishment of paternity, to the extent necessary to establish eligibility for assistance and permit an appropriate referral to the child support recovery unit.  d.  Upon request, the adult applicant or member shall cooperate with the child support recovery unit to the extent of supplying all known information and documents pertaining to the location of the absent parent and taking action as may be necessary to secure medical support and payments for medical care or to establish paternity. This includes completing and signing documents determined to be necessary by the state’s attorney for any relevant judicial or administrative process.  e.  The child support recovery unit shall make the determination of whether or not the adult applicant or member has cooperated for the purposes of this rule.  75.14(2)  Failure of an adult applicant or member to cooperate shall result in denial or cancellation of the noncooperating adult’s Medicaid benefits. In family medical assistance program (FMAP)-related Medicaid cases, all deductions and disregards described at paragraphs 75.57(2)“a,” “b,” and “c” shall be allowed when otherwise applicable.  75.14(3)  Each Medicaid applicant or member who is required to cooperate with the child support recovery unit shall have the opportunity to claim good cause for refusing to cooperate in establishing paternity or securing medical support and payments for medical care. The provisions set forth in subrules 75.14(8) to 75.14(12) shall be used when making a determination of the existence of good cause.  75.14(4)  Each Medicaid applicant or member shall assign to the department any rights to medical support and payments for medical care from any other person for which the person can legally make assignment. This shall include rights to medical support and payments for medical care on the applicant’s or member’s own behalf or on behalf of any other family member for whom the applicant or member is applying. An assignment is effective the same date the eligibility information is entered into the automated benefit calculation system and is effective for the entire period for which eligibility is granted. Support payments not intended for medical support shall not be assigned to the department.  75.14(5)  Rescinded IAB 6/2/10, effective 8/1/10.  75.14(6)  Pregnant women establishing eligibility under the mothers and children (MAC) coverage group as provided at subrule 75.1(28) shall be exempt from the provisions in this rule for any born child for whom the pregnant woman applies for or receives Medicaid. Additionally, any previously pregnant woman eligible for postpartum coverage under the provision of subrule 75.1(24) shall not be subject to the provisions in this rule until after the end of the month in which the 60-day postpartum period expires. Pregnant women establishing eligibility under any other coverage groups except those set forth in subrule 75.1(24) or 75.1(28) shall be subject to the provisions in this rule when establishing eligibility for born children. However, when a pregnant woman who is subject to these provisions fails to cooperate, the woman shall lose eligibility under her current coverage group and her eligibility for Medicaid shall be automatically redetermined under subrule 75.1(28).  75.14(7)  Notwithstanding subrule 75.14(6), any pregnant woman or previously pregnant woman establishing eligibility under subrule 75.1(28) or 75.1(24) shall not be exempt from the provisions of 75.14(4) that require an adult applicant or member to assign any rights to medical support and payments for medical care.  75.14(8)  Good cause for refusal to cooperate. Good cause shall exist when it is determined that cooperation in establishing paternity and securing support is against the best interests of the child.  a.  The income maintenance unit shall determine that cooperation is against the child’s best interest when the applicant’s or member’s cooperation in establishing paternity or securing support is reasonably anticipated to result in:  (1)  Physical or emotional harm to the child for whom support is to be sought; or  (2)  Physical or emotional harm to the parent or specified relative with whom the child is living which reduces the person’s capacity to care for the child adequately.  (3)  Physical harm to the parent or specified relative with whom the child is living which reduces the person’s capacity to care for the child adequately; or  (4)  Emotional harm to the parent or specified relative with whom the child is living of a nature or degree that it reduces the person’s capacity to care for the child adequately.  b.  The income maintenance unit shall determine that cooperation is against the child’s best interest when at least one of the following circumstances exists, and the income maintenance unit believes that because of the existence of that circumstance, in the particular case, proceeding to establish paternity or secure support would be detrimental to the child for whom support would be sought.  (1)  The child was conceived as the result of incest or forcible rape.  (2)  Legal proceedings for the adoption of the child are pending before a court of competent jurisdiction.  (3)  The applicant or member is currently being assisted by a public or licensed private social agency to resolve the issue of whether to keep the child or relinquish the child for adoption, and the discussions have not gone on for more than three months.  c.  Physical harm and emotional harm shall be of a serious nature in order to justify a finding of good cause. A finding of good cause for emotional harm shall be based only upon a demonstration of an emotional impairment that substantially affects the individual’s functioning.  d.  When the good cause determination is based in whole or in part upon the anticipation of emotional harm to the child, the parent, or the specified relative, the following shall be considered:  (1)  The present emotional state of the individual subject to emotional harm.  (2)  The emotional health history of the individual subject to emotional harm.  (3)  Intensity and probable duration of the emotional impairment.  (4)  The degree of cooperation required.  (5)  The extent of involvement of the child in the paternity establishment or support enforcement activity to be undertaken.  75.14(9)  Claiming good cause. Each Medicaid applicant or member who is required to cooperate with the child support recovery unit shall have the opportunity to claim good cause for refusing to cooperate in establishing paternity or securing support payments.  a.  Before requiring cooperation, the department shall notify the applicant or member using Form 470-0169 or 470-0169(S), Requirements of Support Enforcement, of the right to claim good cause as an exception to the cooperation requirement and of all the requirements applicable to a good cause determination.  b.  The initial notice advising of the right to refuse to cooperate for good cause shall:  (1)  Advise the applicant or member of the potential benefits the child may derive from the establishment of paternity and securing support.  (2)  Advise the applicant or member that by law cooperation in establishing paternity and securing support is a condition of eligibility for the Medicaid program.  (3)  Advise the applicant or member of the sanctions provided for refusal to cooperate without good cause.  (4)  Advise the applicant or member that good cause for refusal to cooperate may be claimed and that if the income maintenance unit determines, in accordance with these rules, that there is good cause, the applicant or member will be excused from the cooperation requirement.  (5)  Advise the applicant or member that upon request, or following a claim of good cause, the income maintenance unit will provide further notice with additional details concerning good cause.  c.  When the applicant or member makes a claim of good cause or requests additional information regarding the right to file a claim of good cause, the income maintenance unit shall issue a second notice, Form 470-0170, Requirements of Claiming Good Cause. To claim good cause, the applicant or member shall sign and date Form 470-0170 and return it to the income maintenance unit. This form:  (1)  Indicates that the applicant or member must provide corroborative evidence of good cause circumstance and must, when requested, furnish sufficient information to permit the county office to investigate the circumstances.  (2)  Informs the applicant or member that, upon request, the income maintenance unit will provide reasonable assistance in obtaining the corroborative evidence.  (3)  Informs the applicant or member that on the basis of the corroborative evidence supplied and the agency’s investigation when necessary, the income maintenance unit shall determine whether cooperation would be against the best interests of the child for whom support would be sought.  (4)  Lists the circumstances under which cooperation may be determined to be against the best interests of the child.  (5)  Informs the applicant or member that the child support recovery unit may review the income maintenance unit’s findings and basis for a good cause determination and may participate in any hearings concerning the issue of good cause.  (6)  Informs the applicant or member that the child support recovery unit may attempt to establish paternity and collect support in those cases where the income maintenance unit determines that this can be done without risk to the applicant or member if done without the applicant’s or member’s participation.  d.  The applicant or member who refuses to cooperate and who claims to have good cause for refusing to cooperate has the burden of establishing the existence of a good cause circumstance. Failure to meet these requirements shall constitute a sufficient basis for the income maintenance unit to determine that good cause does not exist. The applicant or member shall:  (1)  Specify the circumstances that the applicant or member believes provide sufficient good cause for not cooperating.  (2)  Corroborate the good cause circumstances.  (3)  When requested, provide sufficient information to permit an investigation.  75.14(10)  Determination of good cause. The income maintenance unit shall determine whether good cause exists for each Medicaid applicant or member who claims to have good cause.  a.  The income maintenance unit shall notify the applicant or member of its determination that good cause does or does not exist. The determination shall:  (1)  Be in writing.  (2)  Contain the income maintenance unit’s findings and basis for determination.  (3)  Be entered in the case record.  b.  The determination of whether or not good cause exists shall be made within 45 days from the day the good cause claim is made. The income maintenance unit may exceed this time standard only when:  (1)  The case record documents that the income maintenance unit needs additional time because the information required to verify the claim cannot be obtained within the time standard, or  (2)  The case record documents that the claimant did not provide corroborative evidence within the time period set forth in subrule 75.14(11).  c.  When the income maintenance unit determines that good cause does not exist:  (1)  The applicant or member shall be so notified and be afforded an opportunity to cooperate, withdraw the application for assistance, or have the case closed; and  (2)  Continued refusal to cooperate will result in the loss of Medicaid for the person who refuses to cooperate.  d.  The income maintenance unit shall make a good cause determination based on the corroborative evidence supplied by the applicant or member only after the income maintenance unit has examined the evidence and found that it actually verifies the good cause claim.  e.  Before making a final determination of good cause for refusing to cooperate, the income maintenance unit shall:  (1)  Afford the child support recovery unit the opportunity to review and comment on the findings and basis for the proposed determination, and  (2)  Consider any recommendation from the child support recovery unit.  f.  The child support recovery unit may participate in any appeal hearing that results from an applicant’s or member’s appeal of an agency action with respect to a decision on a claim of good cause.  g.  Assistance shall not be denied, delayed, or discontinued pending a determination of good cause for refusal to cooperate when the applicant or member has specified the circumstances under which good cause can be claimed and provided the corroborative evidence and any additional information needed to establish good cause.  h.  The income maintenance unit shall:  (1)  Periodically, but not less frequently than every six months, review those cases in which the agency has determined that good cause exists based on a circumstance that is subject to change.  (2)  When it determines that circumstances have changed so that good cause no longer exists, rescind its findings and proceed to enforce the requirements pertaining to cooperation in establishing paternity and securing support.  75.14(11)  Proof of good cause. The applicant or member who claims good cause shall provide corroborative evidence within 20 days from the day the claim was made. In exceptional cases where the income maintenance unit determines that the applicant or member requires additional time because of the difficulty in obtaining the corroborative evidence, the income maintenance unit shall allow a reasonable additional period upon approval by the worker’s immediate supervisor.  a.  A good cause claim may be corroborated with the following types of evidence:  (1)  Birth certificates or medical or law enforcement records which indicate that the child was conceived as the result of incest or forcible rape.  (2)  Court documents or other records which indicate that legal proceedings for adoption are pending before a court of competent jurisdiction.  (3)  Court, medical, criminal, child protective services, social services, psychological, or law enforcement records which indicate that the putative father or absent parent might inflict physical or emotional harm on the child or specified relative.  (4)  Medical records which indicate emotional health history and present emotional health status of the specified relative or the children for whom support would be sought; or written statements from a mental health professional indicating a diagnosis or prognosis concerning the emotional health of the specified relative or the child for whom support would be sought.  (5)  A written statement from a public or licensed private social agency that the applicant or member is being assisted by the agency to resolve the issue of whether to keep the child or relinquish the child for adoption.  (6)  Sworn statements from individuals other than the applicant or member with knowledge of the circumstances which provide the basis for the good cause claim.  b.  When, after examining the corroborative evidence submitted by the applicant or member, the income maintenance unit wishes to request additional corroborative evidence which is needed to permit a good cause determination, the income maintenance unit shall:  (1)  Promptly notify the applicant or member that additional corroborative evidence is needed, and  (2)  Specify the type of document which is needed.  c.  When the applicant or member requests assistance in securing evidence, the income maintenance unit shall:  (1)  Advise the applicant or member how to obtain the necessary documents, and  (2)  Make a reasonable effort to obtain any specific documents which the applicant or member is not reasonably able to obtain without assistance.  d.  When a claim is based on the applicant’s or member’s anticipation of physical harm and corroborative evidence is not submitted in support of the claim:  (1)  The income maintenance unit shall investigate the good cause claim when the office believes that the claim is credible without corroborative evidence and corroborative evidence is not available.  (2)  Good cause shall be found when the claimant’s statement and investigation which is conducted satisfies the county office that the applicant or member has good cause for refusing to cooperate.  (3)  A determination that good cause exists shall be reviewed and approved or disapproved by the worker’s immediate supervisor and the findings shall be recorded in the case record.  e.  The income maintenance unit may further verify the good cause claim when the applicant’s or member’s statement of the claim together with the corroborative evidence do not provide sufficient basis for making a determination. When the income maintenance unit determines that it is necessary, the unit may conduct an investigation of good cause claims to determine that good cause does or does not exist.  f.  When it conducts an investigation of a good cause claim, the income maintenance unit shall:  (1)  Contact the absent parent or putative father from whom support would be sought when the contact is determined to be necessary to establish the good cause claim.  (2)  Before making the necessary contact, notify the applicant or member so the applicant or member may present additional corroborative evidence or information so that contact with the parent or putative father becomes unnecessary, withdraw the application for assistance or have the case closed, or have the good cause claim denied.  75.14(12)  Enforcement without specified relative’s cooperation. When the income maintenance unit makes a determination that good cause exists, the unit shall also make a determination of whether or not child support enforcement can proceed without risk of harm to the child or specified relative when the enforcement or collection activities do not involve their participation.  a.  The child support recovery unit shall have an opportunity to review and comment on the findings and basis for the proposed determination and the income maintenance unit shall consider any recommendations from the child support recovery unit.  b.  The determination shall be in writing, contain the income maintenance unit’s findings and basis for the determination, and be entered into the case record.  c.  When the income maintenance unit excuses cooperation but determines that the child support recovery unit may proceed to establish paternity or enforce support, the income maintenance unit shall notify the applicant or member to enable the individual to withdraw the application for assistance or have the case closed.This rule is intended to implement Iowa Code sections 249A.3 and 249A.4.Related ARC(s): 8785B441—75.15(249A)  Disqualification for long-term care assistance due to substantial home equity.  Notwithstanding any other provision of this chapter, if an individual’s equity interest in the individual’s home exceeds $500,000, the individual shall not be eligible for medical assistance with respect to nursing facility services or other long-term care services except as provided in 75.15(2). This provision is effective for all applications or requests for payment of long-term care services filed on or after January 1, 2006.  75.15(1)  The limit on the equity interest in the individual’s home for purposes of this rule shall be increased from year to year, beginning with 2011, based on the percentage increase in the consumer price index for all urban consumers (all items; United States city average), rounded to the nearest $1,000.  75.15(2)  Disqualification based on equity interest in the individual’s home shall not apply when one of the following persons is lawfully residing in the home:  a.  The individual’s spouse; or  b.  The individual’s child who is under age 21 or is blind or disabled as defined in Section 1614 of the federal Social Security Act.This rule is intended to implement Iowa Code section 249A.4.441—75.16(249A)  Client participation in payment for medical institution care.  Medicaid clients are required to participate in the cost of medical institution care. However, no client participation is charged when the combination of Medicare payments and the Medicaid benefits available to qualified Medicare beneficiaries covers the cost of institutional care.  75.16(1)    Income considered in determining client participation.  The department determines the amount of client participation based on the client’s total monthly income, with the following exceptions:  a.    FMAP-related clients.  The income of a client and family whose eligibility is FMAP-related is not available for client participation when both of the following conditions exist:  (1)  The client has a parent or child at home.  (2)  The family’s income is considered together in determining eligibility.  b.    SSI-related clients who are employed.  If a client receives SSI and is substantially gainfully employed, as determined by the Social Security Administration, the client shall have the SSI and any mandatory state supplementary assistance payment exempt from client participation for the two full months after entry to a medical institution.  c.    SSI-related clients returning home within three months.  If the Social Security Administration continues a client’s SSI or federally administered state supplementary assistance payments for three months because it is expected that the client will return home within three months, these payments shall be exempt from client participation.  d.    Married couples.    (1)  Institutionalized spouse and community spouse. If there is a community spouse, only the institutionalized person’s income shall be considered in determining client participation.  (2)  Both spouses institutionalized. Client participation for each partner in a marriage shall be based on one-half of the couple’s combined income when the partners are considered together for eligibility. Client participation for each partner who is considered individually for eligibility shall be determined individually from each person’s income.  (3)  Rescinded, IAB 7/11/90, effective 7/1/90.  e.    State supplementary assistance recipients.  The amount of client participation that a client paid under the state supplementary assistance program is not available for Medicaid client participation in the month of the client’s entry to a medical institution.  f.    Foster care recipients.  The amount of income paid for foster care for the days that a child is in foster care in the same month as entry to a medical institution is not available for client participation.  g.    Clients receiving a VA pension.  The amount of $90 of veteran’s pension income shall be exempt from client participation if the client is a veteran or a surviving spouse of a veteran who:   (1)  Receives a reduced pension pursuant to 38 U.S.C. Section 5503(d)(2), or  (2)  Resides at the Iowa Veterans Home and does not have a spouse or minor child.  75.16(2)    Allowable deductions from income.  In determining the amount of client participation, the department allows the following deductions from the client’s income, taken in the order they appear:  a.    Ongoing personal needs allowance.  All clients shall retain $50 of their monthly income for a personal needs allowance. (See rules 441—81.23(249A), 441—82.19(249A), and 441—85.47(249A) regarding potential state-funded personal needs supplements.)  (1)  If the client has a trust described in Section 1917(d)(4) of the Social Security Act (including medical assistance income trusts and special needs trusts), a reasonable amount paid or set aside for necessary expenses of the trust is added to the personal needs allowance. This amount shall not exceed $10 per month except with court approval.  (2)  If the client has earned income, an additional $65 is added to the ongoing personal needs allowance from the earned income only.  (3)  Rescinded IAB 7/4/07, effective 7/1/07.  b.    Personal needs in the month of entry.    (1)  Single person. A single person shall be given an allowance for stated home living expenses during the month of entry, up to the amount of the SSI benefit for a single person.  (2)  Spouses entering institutions together and living together. Partners in a marriage who enter a medical institution in the same month and live in the same room shall be given an allowance for stated home living expenses during the month of entry, up to the amount of the SSI benefit for a couple.  (3)  Spouses entering an institution together but living apart. Partners in a marriage who enter a medical institution during the same month and who are considered separately for eligibility shall each be given an allowance for stated home living expenses during the month of entry, up to one-half of the amount of the SSI benefit for a married couple. However, if the income of one spouse is less than one-half of the SSI benefit for a couple, the remainder of the allowance shall be given to the other spouse. If the couple’s eligibility is determined together, an allowance for stated home living expenses shall be given to them during the month of entry up to the SSI benefit for a married couple.  (4)  Community spouse enters a medical institution. When the second member of a married couple enters a medical institution in a later month, that spouse shall be given an allowance for stated expenses during the month of entry, up to the amount of the SSI benefit for one person.  c.    Personal needs in the month of discharge.  The client shall be allowed a deduction for home living expenses in the month of discharge. The amount of the deduction shall be the SSI benefit for one person (or for a couple, if both members are discharged in the same month). This deduction does not apply when a spouse is at home.  d.    Maintenance needs of spouse and other dependents.    (1)  Persons covered. An ongoing allowance shall be given for the maintenance needs of a community spouse. The allowance is limited to the extent that income of the institutionalized spouse is made available to or for the benefit of the community spouse. If there are minor or dependent children, dependent parents, or dependent siblings of either spouse who live with the community spouse, an ongoing allowance shall also be given to meet their needs.  (2)  Income considered. The verified gross income of the spouse and dependents shall be considered in determining maintenance needs. The gross income of the spouse and dependent shall include all monthly earned and unearned income and assistance from the family investment program (FIP), supplemental security income (SSI), and state supplementary assistance (SSA). It shall also include the proceeds of any annuity or contract for sale of real property. Otherwise, the income shall be considered as the SSI program considers income. In addition, the spouse and dependents shall be required to apply for every income benefit for which they are eligible except that they shall not be required to accept SSI, FIP or SSA in lieu of the maintenance needs allowance. Failure to apply for all benefits shall mean reduction of the maintenance needs allowance by the amount of the anticipated income from the source not applied for.  (3)  Needs of spouse. The maintenance needs of the spouse shall be determined by subtracting the spouse’s gross income from the maximum amount allowed as a minimum monthly maintenance needs allowance for the community spouse by Section 1924(d)(3)(C) of the Social Security Act (42 U.S.C. § 1396r-5(d)(3)(C)). (This amount is indexed for inflation annually according to the consumer price index.)However, if either spouse has established through the appeal process that the community spouse needs income above the minimum monthly maintenance needs allowance, due to exceptional circumstances resulting in significant financial duress, an amount adequate to provide additional income as is necessary shall be substituted.Also, if a court has entered an order against an institutionalized spouse for monthly income to support the community spouse, then the community spouse income allowance shall not be less than this amount.  (4)  Needs of other dependents. The maintenance needs of the other dependents shall be established by subtracting each person’s gross income from 133 percent of the monthly federal poverty level for a family of two and dividing the result by three. (Effective July 1, 1992, the percent shall be 150 percent.)  e.    Maintenance needs of children (without spouse).  When the client has children under 21 at home, an ongoing allowance shall be given to meet the children’s maintenance needs.The income of the children is considered in determining maintenance needs. The children’s countable income shall be their gross income less the disregards allowed in the FIP program.The children’s maintenance needs shall be determined by subtracting the children’s countable income from the FIP payment standard for that number of children. (However, if the children receive FIP, no deduction is allowed for their maintenance needs.)  f.    Client’s medical expenses.  A deduction shall be allowed for the client’s incurred expenses for medical or remedial care that are not subject to payment by a third party and were not incurred for long-term care services during the imposition of a transfer of assets penalty period pursuant to rule 441—75.23(249A). This includes Medicare premiums and other health insurance premiums, deductibles or coinsurance, and necessary medical or remedial care recognized under state law but not covered under the state Medicaid plan.This rule is intended to implement Iowa Code sections 249A.3 and 249A.4.Related ARC(s): 8444B441—75.17(249A)  Verification of pregnancy.  For the purpose of establishing Medicaid eligibility for pregnant women under this chapter, the applicant’s self-declaration of the pregnancy and the date of conception shall serve as verification of pregnancy, unless questionable.  75.17(1)    Multiple pregnancy.  If the pregnant woman claims to be carrying more than one fetus, a medical professional who has examined the woman must verify the number of fetuses in order for more than one to be considered in the household size.  75.17(2)    Cost of examination.  When an examination is required and other medical resources are not available to meet the expense of the examination, the provider shall be authorized to make the examination and submit the claim for payment.This rule is intended to implement Iowa Code section 249A.3.441—75.18(249A)  Continuous eligibility for pregnant women.  A pregnant woman who applies for Medicaid prior to the end of her pregnancy and subsequently establishes initial Medicaid eligibility under the provisions of this chapter shall remain continuously eligible throughout the pregnancy and the 60-day postpartum period, as provided in subrule 75.1(24), regardless of any changes in family income.This rule is intended to implement Iowa Code section 249A.3.441—75.19(249A)  Continuous eligibility for children.  A child under the age of 19 who is determined eligible for ongoing Medicaid shall retain that eligibility for up to 12 months regardless of changes in family circumstances except as described in this rule.  75.19(1)    Exceptions to coverage.  This rule does not apply to the following children:  a.  Children whose eligibility was determined under the newborn coverage group described at subrule 75.1(20).  b.  Children whose eligibility was determined under the medically needy coverage group described at subrule 75.1(35).  c.  Children whose medical assistance is state-funded only.  d.  Children whose citizenship is not verified within the “reasonable period” described at paragraph 75.11(2)“c.”  e.  Children who are eligible only in a retroactive month.  75.19(2)    Duration of coverage.  Coverage under this rule shall extend through the earliest of the following months:  a.  The month of the household’s annual eligibility review;  b.  The month when the child reaches the age of 19; or  c.  The month when the child moves out of Iowa.  75.19(3)    Assignment of review date.  Children entering an existing Medicaid household shall be assigned the same annual eligibility review date as that established for the household.This rule is intended to implement Iowa Code Supplement section 249A.3 as amended by 2008 Iowa Acts, House File 2539.Related ARC(s): 8786B, 3353C, 3549C441—75.20(249A)  Disability requirements for SSI-related Medicaid.    75.20(1)    Applicants receiving federal benefits.  An applicant receiving supplemental security income on the basis of disability, social security disability benefits under Title II of the Social Security Act, or railroad retirement benefits based on the Social Security law definition of disability by the Railroad Retirement Board, shall be deemed disabled without further determination of disability.  75.20(2)    Applicants not receiving federal benefits.  When disability has not been established based on the receipt of social security disability or railroad retirement benefits based on the same disability criteria as used by the Social Security Administration, the department shall determine eligibility for SSI-related Medicaid based on disability as follows:  a.  A Social Security Administration (SSA) disability determination under either a social security disability (Title II) application or a supplemental security income application is binding on the department until changed by SSA unless the applicant meets one of the following criteria:  (1)  The applicant alleges a disabling condition different from, or in addition to, that considered by SSA in making its determination.  (2)  The applicant alleges more than 12 months after the most recent SSA determination denying disability that the applicant’s condition has changed or deteriorated since that SSA determination and alleges a new period of disability which meets the durational requirements, and has not applied to SSA for a determination with respect to these allegations.  (3)  The applicant alleges less than 12 months after the most recent SSA determination denying disability that the applicant’s condition has changed or deteriorated since that SSA determination, alleges a new period of disability which meets the durational requirements, and:
    1. The applicant has applied to SSA for reconsideration or reopening of its disability decision and SSA refused to consider the new allegations, or
    2. The applicant no longer meets the nondisability requirements for SSI but may meet the department’s nondisability requirements for Medicaid eligibility.
      b.  When there is no binding SSA decision and the department is required to establish eligibility for SSI-related Medicaid based on disability, initial determinations shall be made by disability determination services, a bureau of the Iowa department of education under the division of vocational rehabilitation services. The applicant or the applicant’s authorized representative shall complete and submit Form 470-4459 or 470-4459(S), Authorization to Disclose Information to the Department of Human Services, and either:  (1)  Form 470-2465, Disability Report for Adults, if the applicant is aged 18 or over; or  (2)  Form 470-3912, Disability Report for Children, if the applicant is under the age of 18.  c.  When an SSA decision on disability is pending when the person applies for Medicaid or when the person applies for either Title II benefits or SSI within ten working days of the Medicaid application, the department shall stay a decision on disability pending the SSA decision on disability.
      75.20(3)    Time frames for decisions.  Determination of eligibility based on disability shall be completed within 90 days unless the applicant or an examining physician delays or fails to take a required action, or there is an administrative or other emergency beyond the department’s or applicant’s control.  75.20(4)    Reviews of disability.  In connection with any independent determination of disability, the department will determine whether reexamination of the member’s disability will be required for periodic eligibility reviews. When a disability review is required, the member or the member’s authorized representative shall complete and submit the same forms as required in paragraph 75.20(2)“b.”  75.20(5)    Members whose disability was determined by the department.  When a Medicaid member has been approved for Medicaid based on disability determined by the department and later is determined by SSA not to be disabled for SSI, the member shall continue to be considered disabled for Medicaid eligibility purposes for 65 days from the date of the SSA denial. If at the end of the 65 days there is no appeal to the SSA, Medicaid shall be canceled with timely notice. If there is an appeal within 65 days, the member shall continue to be considered disabled for Medicaid eligibility purposes until a final SSA decision.  75.20(6)    Disability redeterminations for members who attain age 18.  If a member is eligible based on an independent determination of disability made under the standards applicable to persons under 18 years of age, the department shall redetermine the member’s disability after the member attains the age of 18 years. The member’s disability shall be redetermined:  a.  Using the standards applicable to persons who are 18 years of age or older, and  b.  Regardless of whether a review of the member’s disability would otherwise be due.This rule is intended to implement Iowa Code section 249A.4.
    Related ARC(s): 9044B441—75.21(249A)  Health insurance premium payment (HIPP) program.  Under the HIPP program, the department shall pay for the cost of premiums, coinsurance, copayments, and deductibles for Medicaid-eligible individuals when the department determines that those costs will be less than the cost of paying for the individual’s care through Medicaid including managed care capitation fees. Payment shall include only the cost to the Medicaid-eligible individual or household.  75.21(1)    Definitions.  
    "Absent parent" means a noncustodial parent, or a parent who is not living with the member.
    "Authorized representative" means an individual or organization authorized by a competent applicant or member, authorized by a responsible person acting for an incompetent applicant or member pursuant to 441—subrule 76.9(2), or with other legal authority to represent the applicant or member in the application process, renewal of eligibility and other ongoing communications with the department.
    "Capitation payment" means a monthly payment to the managed care contractor on behalf of each member for the provision of health services under the managed care entity contract. Payment is made by the department regardless of whether the member receives services during the month. The managed care capitation payment varies based on the eligible member’s sex, age, and eligibility aid type.
    "Cost-effective" means a determination has been made that a savings will accrue to the department by paying the insurance premium, cost sharing, wrap benefits, and administrative cost.
    "Cost sharing" means the member’s portions of in-network health care costs not covered by an insurance plan. “Cost sharing” includes copayments, coinsurance and deductibles, which vary among health care plans.
    "Custodian" means the person recognized as representing the interests of the member for Medicaid assistance. When the member reaches the age of 18 and the custodian is not used in determining Medicaid eligibility, there shall be legal documentation in place that the custodian is now the responsible person or authorized representative.
    "Department" means the Iowa department of human services.
    "Employer-sponsored insurance" or “ESI” means any health insurance plan paid for by a business on behalf of its employees.
    "High-deductible health plan" or “HDHP” means a health insurance plan that meets the definition found in Section 223(c)(2) of the Internal Revenue Code.
    "HIPP-eligible member" means a person whose Medicaid eligibility is calculated in the cost-effective determination for HIPP. “HIPP-eligible member” is also referred to as HIPP enrollee.
    "Household" means the group of people who are used in the budgeting and size when determining Medicaid eligibility.
    "Individual plan" means an insurance plan purchased through a government-run health insurance marketplace or through a local broker or agent.
    "Insurance plan" means major medical comprehensive health coverage provided through an employer, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), a government-run health insurance marketplace, or a local broker or agent. Dental and vision plans are not considered to be insurance plans for purposes of this definition.
    "Member" means an individual who has been determined eligible for Medicaid assistance and is enrolled to receive assistance.
    "Policyholder" means the person in whose name an insurance policy is registered.
    "Responsible person" means an individual recognized by the department pursuant to 441—subrule 76.9(1) as acting for an applicant or member who is unable to act on the applicant’s or member’s own behalf because the applicant or member is a minor or is incompetent, incapacitated, or deceased.
    "Wrap benefits" means the services covered under the Medicaid state plans that are not paid for by insurance plans (i.e., waiver services, transportation).
      75.21(2)    Insurance plans.  Participation in an insurance plan is not a condition of Medicaid eligibility. The department shall pay for the cost of the insurance plan premiums, coinsurance, copayment, and deductibles of an insurance plan for a member if:  a.  A member is enrolled in or can be added to the insurance plan; and  b.  The insurance plan is cost-effective as defined in subrule 75.21(3).  75.21(3)    Cost-effectiveness.  An insurance plan shall be considered cost-effective when the amount the department would pay for the member’s insurance premiums, cost sharing, wrap benefits, and administrative costs is likely to be less than the amount the department would pay through Medicaid including managed care capitation fees. When determining the cost-effectiveness of an insurance plan, the following data shall be considered:  a.  The cost to the member or household for the insurance premium, coinsurance, copayments and deductibles. No costs paid by an employer or other plan sponsor shall be considered in the cost-effectiveness determination.  b.  The cost of care through Medicaid including managed care capitation fees the department would pay for the member.  c.  The estimated cost of wrap benefits per member based on the member’s sex, age, and eligibility aid type.  d.  The specific health-related circumstances of the members covered under the health plan. Form 470-2868, HIPP Medical History Questionnaire, shall be used to obtain this information. When the information indicates any health conditions that could be expected to result prospectively in higher-than-average bills for any Medicaid member:  (1)  If the member is currently covered by the insurance plan, the department shall request from the policyholder, or the responsible person for the member, an insurance summary of the member’s paid claims for the previous 12 months. If there is sufficient evidence to indicate that such claims can be expected to continue in the next 12 months, the claims will be considered in determining the cost-effectiveness of the insurance plan. The cost of the insurance plan premium, member’s cost sharing, and administrative cost are compared to the actual claims to determine the cost-effectiveness of providing the coverage.  (2)  If the member was not covered by the health plan in the previous 12 months, fee-for-service paid Medicaid claims may be used to project the cost-effectiveness of the plan.  e.  Annual administrative expenditures of $150 per HIPP member covered under the health plan.  f.  Whether the estimated savings to the department for members covered under the health insurance plan is at least $5 per month per household.  75.21(4)    Coverage of non-Medicaid-eligible family members.  When an insurance plan is determined to be cost-effective, the department shall pay for insurance premiums for non-Medicaid-eligible family members if a non-Medicaid-eligible family member must be enrolled in the insurance plan in order to obtain coverage for the Medicaid-eligible family members. However:  a.  The needs of the non-Medicaid-eligible family members shall not be taken into consideration when determining cost-effectiveness; and  b.  Payments for deductibles, coinsurances or other cost-sharing obligations shall not be made on behalf of family members who are not Medicaid-eligible.  75.21(5)    Insurance plans ineligible for reimbursement.  Premiums shall not be paid for insurance plans under any of the following circumstances:  a.  The insurance plan is that of an absent parent.  b.  The insurance plan is an indemnity policy which supplements the policyholder’s income or pays only a predetermined amount for services covered under the policy (e.g., $50 per day for hospital services instead of 80 percent of the charge).  c.  The insurance plan is a school plan offered on the basis of attendance or enrollment at the school.  d.  The insurance premium is used to meet a spenddown obligation under the medically needy program, as provided in subrule 75.1(35), when all persons in the household are eligible or potentially eligible only under the medically needy program. When some of the household members are eligible for full Medicaid benefits under coverage groups other than medically needy, the premium shall be paid if it is determined to be cost-effective when considering only the persons receiving full Medicaid coverage. In those cases, the insurance premium shall not be allowed as a deduction to meet the spenddown obligation for those persons in the household participating in the medically needy program.  e.  The insurance plan is designed to provide coverage only for a temporary period of time (e.g., 30 to 180 days).  f.  The persons covered under the insurance plan are not Medicaid-eligible on the date the decision regarding eligibility for the HIPP program is made. No retroactive payments shall be made if the case is not Medicaid-eligible on the date of decision.  g.  The person is eligible only for a coverage group that does not provide full Medicaid services.  h.  Insurance coverage is provided through the health insurance plan of Iowa (HIPIOWA), in accordance with Iowa Code chapter 514E.  i.  Insurance on the member(s) is maintained by someone who does not live with the member(s), is not the legal guardian of the member(s), is not a responsible person, or does not have legal permission to access the Medicaid information of the member(s) (e.g., self-supporting adult children).  j.  The member has Medicare. If other members in the household are covered by the insurance plan, cost-effectiveness is determined without including the Medicare-covered member.  k.  The insurance plan does not provide major medical coverage but pays only for specific situations (i.e., accident plans) or illnesses (i.e., cancer policy).  l.  The health plan pays secondary to another plan.  m.  The only Medicaid member is in foster care.  n.  The member is active for Medicaid under Medicaid for children with disabilities (i.e., Medicaid for kids with special needs (MKSN)), pursuant to subrule 75.1(43). Any other Medicaid members in the household who are covered by the health plan shall be determined for cost-effectiveness.  o.  The insurance plan is limited due to preexisting conditions.  p.  The insurance plan is a subsidized insurance plan purchased through a government-run health insurance exchange.  q.  On the date the decision regarding eligibility for the HIPP program is made, the insurance is no longer available.  r.  The insurance plan is an HDHP.  75.21(6)    Department evaluation of ESI plans.  When evaluating ESI plans available through an employer, if there is more than one cost-effective insurance plan available, the department shall pay the premium for only one plan. The member may choose the cost-effective plan in which to enroll.  75.21(7)    Effective date of premium payment.  The effective date of premium payments for a cost-effective health plan shall be determined as follows:  a.  Premium payments shall begin the later of:  (1)  The first day of the month in which Form 470-2844, Employer’s Statement of Earnings; Form 470-2875, Health Insurance Premium Payment (HIPP) Program Application; or Form H301-1, the automated HIPP referral; is received by the HIPP unit; or  (2)  The first day of the first month in which the health plan is determined to be cost-effective.  b.  If the person is not enrolled in the insurance plan when eligibility for participation in the HIPP program is established, premium payments shall begin in the month in which the first premium payment is due after enrollment occurs.  c.  If there was a lapse in coverage during the application process (e.g., the health plan is dropped and reenrollment occurs at a later date), premium payments shall not be made for any period of time before the current effective date of coverage.  d.  In no case shall payments be made for premiums that were used as a deduction to income for determining client participation or the amount of the spenddown obligation.  e.  Form 470-3036, Employer Verification of Insurance Coverage, shall be used to verify the effective date of coverage and costs for persons enrolled in group health plans through an employer.  f.  The effective date of coverage of an insurance plan not obtained through an employer shall be verified by a copy of the certificate of coverage for the plan or by some other verification from the insurer.  75.21(8)    Method of premium payment.  Payments of premiums will be made directly to the insurance carrier except as follows:  a.  The department may arrange for payment to an employer in order to circumvent a payroll deduction.  b.  When an employer will not agree to accept premium payments from the department in lieu of a payroll deduction to the employee’s wages, the department shall reimburse the employee directly for payroll deductions or for payments made directly to the employer for the payment of premiums. The department shall issue reimbursement to the employee five working days before the employee’s pay date.  c.  When premium payments are occurring through an automatic withdrawal from a bank account by the insurance carrier, the department may reimburse the policyholder for those withdrawals.  d.  Payments for COBRA coverage shall be made directly to the insurance carrier, the COBRA administrator, or the former employer. Payments may be made directly to the former employee only in those cases where:  (1)  Information cannot be obtained for direct payment; or  (2)  The department pays for only part of the total premium.  75.21(9)    Payment of claims.  Claims from medical providers for persons participating in this program shall be paid in the same manner as claims are paid for other persons with a third-party resource in accordance with the provisions of 441—Chapters 79 and 80.  75.21(10)    Reviews of cost-effectiveness and eligibility.  Reviews of cost-effectiveness and eligibility shall be completed annually and may be conducted more frequently at the discretion of the department.  a.  Annual review of ESI cost-effectiveness and eligibility shall be completed using Form 470-3016, Health Insurance Premium Payment (HIPP) Program Review.  b.  Annual review of individual health plan cost-effectiveness and eligibility shall be completed using Form 470-3017, HIPP Private Policy Review.  c.  Failure of the household to cooperate in the annual review process shall result in cancellation of premium payment.  d.  Redeterminations shall be completed whenever:  (1)  A premium rate, copayment, deductible, or coinsurance changes;  (2)  A person covered under the policy loses full Medicaid eligibility;  (3)  Changes in employment or hours of employment affect the availability of an insurance plan;  (4)  The insurance carrier changes;  (5)  The policyholder leaves the Medicaid home;  (6)  There is a decrease in the services covered under the policy; or  (7)  The Medicaid category of coverage changes.  e.  The policyholder shall report changes that may affect the availability of the insurance plan reimbursed by the HIPP program, or changes that affect the cost-effectiveness of the policy, within ten calendar days from the date of the change.  f.  If a change in the number of members in the Medicaid household causes the health plan not to be cost-effective, lesser health plan options, as defined in paragraph 75.21(15)“a,” shall be considered if available and cost-effective.  g.  When employment ends, hours of employment are reduced, or some other qualifying event affecting the availability of the group health plan occurs, the department shall verify whether coverage may be continued under the provisions of COBRA.  (1)  Form 470-3037, Employer Verification of COBRA Eligibility, may be used for this purpose.  (2)  If cost-effective to do so, the department shall pay premiums to maintain insurance coverage for members after the occurrence of the event which would otherwise result in termination of coverage.  75.21(11)    Time frames for determining cost-effectiveness.  The department shall determine cost-effectiveness of the insurance plan and notify the applicant of the decision regarding payment of the premiums within 65 calendar days from the date an application or referral (as defined in subrule 75.21(7)) is received. Additional time may be taken when, for reasons beyond the control of the department or the applicant, information needed to establish cost-effectiveness cannot be obtained within the 65-day period.  75.21(12)    Notices.    a.  Adequate notice shall be provided to the household under the following circumstances:  (1)  To inform the household of the initial decision on cost-effectiveness and premium payment.  (2)  To inform the household that premium payments are being discontinued because Medicaid eligibility has been lost by all persons covered under the health plan.  (3)  The insurance plan is no longer available to the family (e.g., the employer no longer provides health insurance coverage or the policy is terminated by the insurance company).  b.  The department shall provide timely and adequate notice as defined in 441—subrule 7.7(1) to inform the household of a decision to discontinue payment of the health insurance premium because:  (1)  The department has determined the insurance plan is no longer cost-effective; or  (2)  The member has failed to cooperate in providing information necessary to establish continued eligibility for the HIPP program.  75.21(13)    Rate refund.  The department shall be entitled to any rate refund made when the insurance carrier determines a return of premiums to the policyholder is due for any time period for which the department paid the premium.  75.21(14)    Reinstatement of HIPP eligibility.    a.  When eligibility for the HIPP program is canceled because the persons covered under the insurance plan lose Medicaid eligibility, HIPP eligibility shall be reinstated when Medicaid eligibility is reestablished if all other eligibility factors are met.  b.  When HIPP eligibility is canceled because of the policyholder’s failure to cooperate in providing information necessary to establish continued eligibility for the HIPP program, benefits shall be reinstated the first day of the first month in which cooperation occurs, if all other eligibility factors are met.  75.21(15)    Amount of insurance premium paid.    a.  For ESI plans, the policyholder shall provide verification of the cost of all possible insurance plan options (i.e., single, employee/children, family).  (1)  The HIPP program shall pay only for the option that provides coverage to the cost-effective members of the household.  (2)  The HIPP program shall not pay the portion of the premium cost which is the responsibility of the employer or other plan sponsor.  b.  For individual health plans, the HIPP program shall pay the cost of covering the cost-effective members covered by the plan.  c.  For insurance plans, if another household member must be covered to obtain coverage for the members, the HIPP program shall pay the cost of covering that household member if the coverage is cost-effective as determined pursuant to subrules 75.21(3) and 75.21(4).  75.21(16)    Reporting changes.  Failure to report and verify changes may result in cancellation of HIPP benefits.  a.  The policyholder shall verify changes by providing a pay stub, a summary of benefits and coverage, a rate sheet, or a letter from the insurance carrier reflecting the change.  b.  Changes in employment or the employment-related insurance carrier shall be verified by the employer.  c.  Any benefits paid during a period in which there was ineligibility for HIPP due to unreported changes shall be subject to recovery in accordance with the provisions of 441—Chapter 11.  d.  Any underpayment that results from an unreported change shall be paid effective the first day of the month in which the change is reported.  75.21(17)    Discontinuation of premium payments.    a.  When the household loses Medicaid eligibility, premium payments shall be discontinued as of the month of Medicaid ineligibility.  b.  When only part of the household loses Medicaid eligibility, the department shall complete a review in order to ascertain whether payment of the health insurance premium continues to be cost-effective. If the department determines that the insurance plan is no longer cost-effective, premium payment shall be discontinued pending timely and adequate notice.  c.  If the household fails to cooperate in providing information necessary to establish ongoing eligibility for the HIPP program, the department shall discontinue premium payment after timely and adequate notice. The department shall request all information in writing and allow the household ten calendar days in which to provide it.  d.  If the policyholder leaves the Medicaid household, premium payments shall be discontinued pending timely and adequate notice.  e.  If the insurance plan is no longer available or the policy has lapsed, premium payments shall be discontinued as of the effective date of the termination of the coverage.This rule is intended to implement Iowa Code section 249A.3.
    Related ARC(s): 3493C441—75.22(249A)  AIDS/HIV health insurance premium payment program.  For the purposes of this rule, “AIDS” and “HIV” are defined in accordance with Iowa Code section 141A.1.  75.22(1)    Conditions of eligibility.  The department shall pay for the cost of continuing health insurance coverage to persons with AIDS or HIV-related illnesses when the following criteria are met:  a.  The person with AIDS or HIV-related illness shall be the policyholder, or the spouse of the policyholder, of an individual or group health plan.  b.  The person shall be a resident of Iowa in accordance with the provisions of rule 441—75.10(249A).  c.  The person shall not be eligible for Medicaid. The person shall be required to apply for Medicaid benefits when it appears Medicaid eligibility may exist. Persons who are required to meet a spenddown obligation under the medically needy program, as provided in subrule 75.1(35), are not considered Medicaid-eligible for the purpose of establishing eligibility under these provisions.When Medicaid eligibility is attained, premium payments shall be made under the provisions of rule 441—75.21(249A) if all criteria of that rule are met.  d.  A physician’s statement shall be provided verifying the policyholder or the spouse of the policyholder suffers from AIDS or an HIV-related illness. The physician’s statement shall also verify that the policyholder or the spouse of the policyholder is or will be unable to continue employment in the person’s current position or that hours of employment will be significantly reduced due to AIDS or HIV-related illness. The Physician’s Verification of Diagnosis, Form 470-2958, shall be used to obtain this information from the physician.  e.  Gross income shall not exceed 300 percent of the federal poverty level for a family of the same size. The gross income of all family members shall be counted using the definition of gross income under the supplemental security income (SSI) program.  f.  Liquid resources shall not exceed $10,000 per household. The following are examples of countable resources:  (1)  Unobligated cash.  (2)  Bank accounts.  (3)  Stocks, bonds, certificates of deposit, excluding Internal Revenue Service defined retirement plans.  g.  The health insurance plan must be cost-effective based on the amount of the premium and the services covered.  75.22(2)    Application process.    a.    Application.  Persons applying for participation in this program shall complete the AIDS/HIV Health Insurance Premium Payment Application, Form 470-2953. The applicant shall be required to provide documentation of income and assets. The application shall be available from and may be filed at any county departmental office or at the Division of Medical Services, Department of Human Services, Hoover State Office Building, 1305 East Walnut, Des Moines, Iowa 50319-0114.An application shall be considered as filed on the date an AIDS/HIV Health Insurance Premium Payment Application, Form 470-2953, containing the applicant’s name, address and signature is received and date-stamped in any county departmental office or the division of medical services.  b.    Time limit for decision.  Every reasonable effort will be made to render a decision within 30 days. Additional time for rendering a decision may be taken when, due to circumstances beyond the control of the applicant or the department, a decision regarding the applicant’s eligibility cannot be reached within 30 days (e.g., verification from a third party has not been received).  c.    Eligible on the day of decision.  No payments will be made for current or retroactive premiums if the person with AIDS or an HIV-related illness is deceased prior to a final eligibility determination being made on the application, if the insurance plan has lapsed, or if the person has otherwise lost coverage under the insurance plan.  d.    Waiting list.  After funds appropriated for this purpose are obligated, pending applications shall be denied by the division of medical services. A denial shall require a notice of decision to be mailed within ten calendar days following the determination that funds have been obligated. The notice shall state that the applicant meets eligibility requirements but no funds are available and that the applicant will be placed on the waiting list, or that the applicant does not meet eligibility requirements. Applicants not awarded funding who meet the eligibility requirements will be placed on a statewide waiting list according to the order in which the completed applications were filed. In the event that more than one application is received at one time, applicants shall be entered on the waiting list on the basis of the day of the month of the applicant’s birthday, lowest number being first on the waiting list. Any subsequent tie shall be decided by the month of birth, January being month one and the lowest number.  75.22(3)    Presumed eligibility  The applicant may be presumed eligible to participate in the program for a period of two calendar months or until a decision regarding eligibility can be made, whichever is earlier. Presumed eligibility shall be granted when:  a.  The application is accompanied by a completed Physician’s Verification of Diagnosis, Form 470-2958.  b.  The application is accompanied by a premium statement from the insurance carrier indicating the policy will lapse before an eligibility determination can be made.  c.  It can be reasonably anticipated that the applicant will be determined eligible from income and resource statements on the application.  75.22(4)    Family coverage.  When the person is enrolled in a policy that provides health insurance coverage to other members of the family, only that portion of the premium required to maintain coverage for the policyholder or the policyholder’s spouse with AIDS or an HIV-related illness shall be paid under this rule unless modification of the policy would result in a loss of coverage for the person with AIDS or an HIV-related illness.  75.22(5)    Method of premium payment.  Premiums shall be paid in accordance with the provisions of subrule 75.21(8).  75.22(6)    Effective date of premium payment.  Premium payments shall be effective with the month of application or the effective date of eligibility, whichever is later.  75.22(7)    Reviews.  The circumstances of persons participating in the program shall be reviewed quarterly to ensure eligibility criteria continues to be met. The AIDS/HIV Health Insurance Premium Payment Program Review, Form 470-2877, shall be completed by the recipient or someone acting on the recipient’s behalf for this purpose.  75.22(8)    Termination of assistance.  Premium payments for otherwise eligible persons shall be paid under this rule until one of the following conditions is met:  a.  The person becomes eligible for Medicaid. In which case, premium payments shall be paid in accordance with the provisions of rule 441—75.21(249A).  b.  The insurance coverage is no longer available.  c.  Maintaining the insurance plan is no longer considered the most cost-effective way to pay for medical services.  d.  Funding appropriated for the program is exhausted.  e.  The person with AIDS or an HIV-related illness dies.  f.  The person fails to provide requested information necessary to establish continued eligibility for the program.  75.22(9)    Notices.    a.  An adequate notice as defined in 441—subrule 7.7(1) shall be provided under the following circumstances:  (1)  To inform the applicant of the initial decision regarding eligibility to participate in the program.  (2)  To inform the recipient that premium payments are being discontinued under these provisions because Medicaid eligibility has been attained and premium payments will be made under the provisions of rule 441—75.21(249A).  (3)  To inform the recipient that premium payments are being discontinued because the policy is no longer available.  (4)  To inform the recipient that premium payments are being discontinued because funding for the program is exhausted.  (5)  The person with AIDS or an HIV-related illness dies.  b.  A timely and adequate notice as defined in 441—subrule 7.7(1) shall be provided to the recipient informing the recipient of a decision to discontinue payment of the health insurance premium when the recipient no longer meets the eligibility requirements of the program or fails to cooperate in providing information to establish eligibility.  75.22(10)    Confidentiality.  The department shall protect the confidentiality of persons participating in the program in accordance with Iowa Code section 141A.9. When it is necessary for the department to contact a third party to obtain information in order to determine initial or ongoing eligibility, a Consent to Obtain and Release Information, Form 470-0429, shall be signed by the recipient authorizing the department to make the contact.This rule is intended to implement Iowa Code section 249A.4.441—75.23(249A)  Disposal of assets for less than fair market value after August 10, 1993.  In determining Medicaid eligibility for persons described in 441—Chapters 75 and 83, a transfer of assets occurring after August 10, 1993, will affect Medicaid payment for medical services as provided in this rule.  75.23(1)    Ineligibility for services.  When an individual or spouse has transferred or disposed of assets for less than fair market value as defined in 75.23(11) on or after the look-back date specified in 75.23(2), the individual shall be ineligible for medical assistance as provided in this subrule.  a.    Institutionalized individual.  When an institutionalized individual or the spouse of the individual disposed of assets for less than fair market value on or after the look-back date, the institutionalized individual is ineligible for medical assistance payment for nursing facility services, a level of care in any institution equivalent to that of nursing facility services, and home- and community-based waiver services. The period of ineligibility is equal to the number of months specified in 75.23(3). The department shall determine the beginning of the period of ineligibility as follows:  (1)  Transfer before February 8, 2006. When the transfer of assets was made before February 8, 2006, the period of ineligibility shall begin on the first day of the first month during which the assets were transferred, except as provided in subparagraph (3).  (2)  Transfer on or after February 8, 2006. Within the limits of subparagraph (3), when the transfer of assets was made on or after February 8, 2006, the period of ineligibility shall begin on the later of:
    1. The first day of the first month during which the assets were transferred; or
    2. The date on which the individual is eligible for medical assistance under this chapter and would be receiving nursing facility services, a level of care in any institution equivalent to that of nursing facility services, or home- and community-based waiver services, based on an approved application for such care, but for the application of this rule.
      (3)  Exclusive period. The period of ineligibility due to the transfer shall not begin during any other period of ineligibility under this rule.
      b.    Noninstitutionalized individual.  When a noninstitutionalized individual or the spouse of the individual disposed of assets for less than fair market value on or after the look-back date, the individual is ineligible for medical assistance payment for home health care services, home and community care for functionally disabled elderly individuals, personal care services, and other long-term care services. The period of ineligibility is equal to the number of months specified in 75.23(3). The department shall determine the beginning of the period of ineligibility as follows:  (1)  Transfer before February 8, 2006. When the transfer of assets was made before February 8, 2006, the period of ineligibility shall begin on the first day of the first month during which the assets were transferred, except as provided in subparagraph (3).  (2)  Transfer on or after February 8, 2006. Within the limits of subparagraph (3), when the transfer of assets was made on or after February 8, 2006, the period of ineligibility shall begin on the later of:
    1. The first day of the first month during which the assets were transferred; or
    2. The date on which the individual is eligible for medical assistance under this chapter and would be receiving home health care services, home and community care for functionally disabled elderly individuals, personal care services, or other long-term care services, based on an approved application for such care, but for the application of this rule.
      (3)  Exclusive period. The period of ineligibility due to the transfer shall not begin during any other period of ineligibility under this rule.
      c.    Client participation after period of ineligibility.  Expenses incurred for long-term care services during a transfer of assets penalty period may not be deducted as medical expenses in determining client participation pursuant to subrule 75.16(2).
      75.23(2)    Look-back date.    a.    Transfer before February 8, 2006.  For transfers made before February 8, 2006, the look-back date is the date that is 36 months (or, in the case of payments from a trust or portion of a trust that are treated as assets disposed of by the individual, 60 months) before:  (1)  The date an institutionalized individual is both an institutionalized individual and has applied for medical assistance; or  (2)  The date a noninstitutionalized individual applies for medical assistance.  b.    Transfer on or after February 8, 2006.  For transfers made on or after February 8, 2006, the look-back date is the date that is 60 months before:  (1)  The date an institutionalized individual is both an institutionalized individual and has applied for medical assistance; or  (2)  The date a noninstitutionalized individual applies for medical assistance.  75.23(3)    Period of ineligibility.  The number of months of ineligibility shall be equal to the total cumulative uncompensated value of all assets transferred by the individual (or the individual’s spouse) on or after the look-back date specified in subrule 75.23(2), divided by the statewide average private-pay rate for nursing facility services at the time of application. The department shall determine the average statewide cost to a private-pay resident for nursing facilities and update the cost annually. Current average statewide costs shall be published on the department’s website.  75.23(4)    Reduction of period of ineligibility.  The number of months of ineligibility otherwise determined with respect to the disposal of an asset shall be reduced by the months of ineligibility applicable to the individual prior to a change in institutional status.  75.23(5)    Exceptions.  An individual shall not be ineligible for medical assistance, under this rule, to the extent that:  a.  The assets transferred were a home and title to the home was transferred to either:  (1)  A spouse of the individual.  (2)  A child of the individual who is under the age of 21 or is blind or permanently and totally disabled as defined in 42 U.S.C. Section 1382c.  (3)  A sibling of the individual who has an equity interest in the home and who was residing in the individual’s home for a period of at least one year immediately before the individual became institutionalized.  (4)  A son or daughter of the individual who was residing in the individual’s home for a period of at least two years immediately before the date of institutionalization and who provided care to the individual which permitted the individual to reside at home rather than in an institution or facility.  b.  The assets were transferred:  (1)  To the individual’s spouse or to another for the sole benefit of the individual’s spouse.  (2)  From the individual’s spouse to another for the sole benefit of the individual’s spouse.  (3)  To a child of the individual who is blind or permanently and totally disabled as defined in 42 U.S.C. Section 1382c or to a trust established solely for the benefit of such a child.  (4)  To a trust established solely for the benefit of an individual under 65 years of age who is disabled as defined in 42 U.S.C. Section 1382c.  c.  A satisfactory showing is made that one of the following is true:  (1)  The individual intended to dispose of the assets either at fair market value, or for other valuable consideration.  (2)  The assets were transferred exclusively for a purpose other than to qualify for medical assistance.  (3)  All assets transferred for less than fair market value have been returned to the individual.  d.  The denial of eligibility would work an undue hardship. Undue hardship shall exist only when all of the following conditions are met:  (1)  Application of the transfer of asset penalty would deprive the individual of medical care such that the individual’s health or life would be endangered or of food, clothing, shelter, or other necessities of life.  (2)  The person who transferred the resource or the person’s spouse has exhausted all means including legal remedies and consultation with an attorney to recover the resource.  (3)  The person’s remaining available resources (after the attribution for the community spouse) are less than the monthly statewide average cost of nursing facility services to a private pay resident, counting the value of all resources except for:
    1. The home if occupied by a dependent relative or if a licensed physician verifies that the person is expected to return home.
    2. Household goods.
    3. A vehicle required by the client for transportation.
    4. Funds for burial of $4,000 or less.
    Hardship will not be found if the resource was transferred to a person who was handling the financial affairs of the client or to the spouse or children of a person handling the financial affairs of the client unless the client demonstrates that payments cannot be obtained from the funds of the person who handled the financial affairs to pay for long-term care services.
      75.23(6)    Assets held in common.  In the case of an asset held by an individual in common with another person or persons in a joint tenancy, tenancy in common, or similar arrangement, the asset, or the affected portion of the asset, shall be considered to be transferred by the individual when any action is taken, either by the individual or by any other person, that reduces or eliminates the individual’s ownership or control of the asset.  75.23(7)    Transfer by spouse.  In the case of a transfer by a spouse of an individual which results in a period of ineligibility for medical assistance under the state plan for the individual, the period of ineligibility shall be apportioned between the individual and the individual’s spouse if the spouse otherwise becomes eligible for medical assistance under the state plan. The remaining penalty period shall be evenly divided on a monthly basis, with any remaining month of penalty (prorated as a half month to each spouse) applied to the spouse who initiated the transfer action.If a spouse subsequently dies prior to the end of the penalty period, the remaining penalty period shall be applied to the surviving spouse’s period of ineligibility.  75.23(8)    Definitions.  In this rule the following definitions apply:
    "Assets" shall include all income and resources of the individual and the individual’s spouse, including any income or resources which the individual or the individual’s spouse is entitled to but does not receive because of action by:
    1. The individual or the individual’s spouse.
    2. A person, including a court or administrative body, with legal authority to act in place of or on behalf of the individual or the individual’s spouse.
    3. Any person, including any court or administrative body, acting at the direction or upon the request of the individual or the individual’s spouse.
    "Income" shall be defined by 42 U.S.C. Section 1382a.
    "Institutionalized individual" shall mean an individual who is an inpatient in a nursing facility, who is an inpatient in a medical institution and with respect to whom payment is made based on a level of care provided in a nursing facility or who is eligible for home- and community-based waiver services.
    "Resources" shall be defined by 42 U.S.C. Section 1382b without regard (in the case of an institutionalized individual) to the exclusion of the home and land appertaining thereto.
    "Transfer or disposal of assets" means any transfer or assignment of any legal or equitable interest in any asset as defined above, including:
    1. Giving away or selling an interest in an asset;
    2. Placing an interest in an asset in a trust that is not available to the grantor (see 75.24(2)“b”(2));
    3. Removing or eliminating an interest in a jointly owned asset in favor of other owners;
    4. Disclaiming an inheritance of any property, interest, or right pursuant to Iowa Code section 633.704 on or after July 1, 2000 (see Iowa Code section 249A.3(11)“c”);
    5. Failure to take a share of an estate as a surviving spouse (also known as “taking against a will”) on or after July 1, 2000, to the extent that the value received by taking against the will would have exceeded the value of the inheritance received under the will (see Iowa Code section 249A.3(11)“d”); or
    6. Transferring or disclaiming the right to income not yet received.
      75.23(9)    Purchase of annuities.  Funds used to purchase an annuity for more than its fair market value shall be treated as assets transferred for less than fair market value regardless of when the annuity was purchased or whether the conditions described in this subrule were met.  a.  The entire amount used to purchase an annuity on or after February 8, 2006, with a Medicaid applicant or member as the annuitant shall be treated as assets transferred for less than fair market value unless the annuity meets one of the conditions described in paragraph 75.23(9)“b” and also meets the condition described in paragraph 75.23(9)“c.”  b.  To be exempted from treatment as an asset transferred at less than fair market value, an annuity described in paragraph 75.23(9)“a” must meet one of the following conditions:  (1)  The annuity is an annuity described in Subsection (b) or (q) of Section 408 of the United States Internal Revenue Code of 1986.  (2)  The annuity is purchased with proceeds from:
    1. An account or trust described in Subsection (a), (c), or (p) of Section 408 of the United States Internal Revenue Code of 1986;
    2. A simplified employee pension (within the meaning of Section 408(k) of the United States Internal Revenue Code of 1986); or
    3. A Roth IRA described in Section 408A of the United States Internal Revenue Code of 1986.
      (3)  The annuity:
    1. Is irrevocable and nonassignable;
    2. Is actuarially sound (as determined in accordance with actuarial publications of the Office of the Chief Actuary of the United States Social Security Administration); and
    3. Provides for payments in equal amounts during the term of the annuity, with no deferral and no balloon payments made.
      c.  To be exempted from treatment as an asset transferred at less than fair market value, an annuity described in paragraph 75.23(9)“a” must have Iowa named as the remainder beneficiary for at least the total amount of medical assistance paid on behalf of the annuitant or the annuitant’s spouse, if either is institutionalized. Iowa may be named either:  (1)  In the first position; or  (2)  In the second position after the spouse or minor or disabled child and in the first position if the spouse or a representative of the child disposes of any of the remainder for less than fair market value.  d.  The entire amount used to purchase an annuity on or after February 8, 2006, with the spouse of a Medicaid applicant or member as the annuitant shall be treated as assets transferred for less than fair market value unless Iowa is named as the remainder beneficiary for at least the total amount of medical assistance paid on behalf of the annuitant or the annuitant’s spouse, if either is institutionalized. Iowa may be named either:  (1)  In the first position; or  (2)  In the second position after the spouse or minor or disabled child and in the first position if the spouse or a representative of the child disposes of any of the remainder for less than fair market value.
      75.23(10)    Purchase of promissory notes, loans, or mortgages.    a.  Funds used to purchase a promissory note, loan, or mortgage after February 8, 2006, shall be treated as assets transferred for less than fair market value in the amount of the outstanding balance due on the note, loan, or mortgage as of the date of the individual’s application for medical assistance for services described in 75.23(1), unless the note, loan, or mortgage meets all of the following conditions:  (1)  The note, loan, or mortgage has a repayment term that is actuarially sound (as determined in accordance with actuarial publications of the Office of the Chief Actuary of the United States Social Security Administration).  (2)  The note, loan, or mortgage provides for payments to be made in equal amounts during the term of the loan, with no deferral and no balloon payments made.  (3)  The note, loan, or mortgage prohibits the cancellation of the balance upon the death of the lender.  b.  Funds used to purchase a promissory note, loan, or mortgage for less than its fair market value shall be treated as assets transferred for less than fair market value regardless of whether:  (1)  The note, loan, or mortgage was purchased before February 8, 2006; or  (2)  The note, loan, or mortgage was purchased on or after February 8, 2006, and the conditions described in 75.23(9)“a” were met.  75.23(11)    Purchase of life estates.    a.  The entire amount used to purchase a life estate in another individual’s home after February 8, 2006, shall be treated as assets transferred for less than fair market value, unless the purchaser resides in the home for at least one year after the date of the purchase.  b.  Funds used to purchase a life estate in another individual’s home for more than its fair market value shall be treated as assets transferred for less than fair market value regardless of whether:  (1)  The life estate was purchased before February 8, 2006; or  (2)  The life estate was purchased on or after February 8, 2006, and the purchaser resided in the home for one year after the date of purchase.This rule is intended to implement Iowa Code sections 249A.3 and 249A.4.
    Related ARC(s): 7834B, 8444B, 8898B, 9404B, 9582B, 0192C, 0821C, 1484C, 2027C, 2605C, 3183C, 3869C, 4572C441—75.24(249A)  Treatment of trusts established after August 10, 1993.  For purposes of determining an individual’s eligibility for, or the amount of, medical assistance benefits, trusts established after August 10, 1993, (except for trusts specified in 75.24(3)) shall be treated in accordance with 75.24(2).  75.24(1)    Establishment of trust.    a.  For the purposes of this rule, an individual shall be considered to have established a trust if assets of the individual were used to form all or part of the principal of the trust and if any of the following individuals established the trust other than by will: the individual, the individual’s spouse, a person (including a court or administrative body, with legal authority to act in place of or on behalf of the individual or the individual’s spouse), or a person (including a court or administrative body) acting at the direction or upon the request of the individual or the individual’s spouse.  b.  The term “assets,” with respect to an individual, includes all income and resources of the individual and of the individual’s spouse, including any income or resources which the individual or the individual’s spouse is entitled to but does not receive because of action by the individual or the individual’s spouse, by a person (including a court or administrative body, with legal authority to act in place of or on behalf of the individual’s spouse), or by any person (including a court or administrative body) acting at the direction or upon the request of the individual or the individual’s spouse.  c.  In the case of a trust, the principal of which includes assets of an individual and assets of any other person or persons, the provisions of this rule shall apply to the portion of the trust attributable to the individual.  d.  This rule shall apply without regard to:  (1)  The purposes for which a trust is established.  (2)  Whether the trustees have or exercise any discretion under the trust.  (3)  Any restrictions on when or whether distribution may be made for the trust.  (4)  Any restriction on the use of distributions from the trust.  e.  The term “trust” includes any legal instrument or device that is similar to a trust, including a conservatorship.  75.24(2)    Treatment of revocable and irrevocable trusts.    a.  In the case of a revocable trust:  (1)  The principal of the trust shall be considered an available resource.  (2)  Payments from the trust to or for the benefit of the individual shall be considered income of the individual.  (3)  Any other payments from the trust shall be considered assets disposed of by the individual, subject to the penalties described at rule 441—75.23(249A) and 441—Chapter 89.  b.  In the case of an irrevocable trust:  (1)  If there are any circumstances under which payment from the trust could be made to or for the benefit of the individual, the portion of the principal from which, or the income on the principal from which, payment to the individual could be made shall be considered an available resource to the individual and payments from that principal or income to or for the benefit of the individual shall be considered income to the individual. Payments for any other purpose shall be considered a transfer of assets by the individual subject to the penalties described at rule 441—75.23(249A) and 441—Chapter 89.  (2)  Any portion of the trust from which, or any income on the principal from which, no payment could under any circumstances be made to the individual shall be considered, as of the date of establishment of the trust (or, if later, the date on which payment to the individual was foreclosed) to be assets disposed of by the individual subject to the penalties specified at 75.23(3) and 441—Chapter 89. The value of the trust shall be determined for this purpose by including the amount of any payments made from this portion of the trust after this date.  75.24(3)    Exceptions.  This rule shall not apply to any of the following trusts:  a.  A trust containing the assets of an individual under the age of 65 who is disabled (as defined in Section 1614(a)(3) of the Social Security Act) and which is established for the benefit of the individual by a parent, grandparent, legal guardian of the individual, or a court if the state will receive all amounts remaining in the trust upon the death of the individual up to an amount equal to the total medical assistance paid on behalf of the individual.  b.  A trust established for the benefit of an individual if the trust is composed only of pension, social security, and other income to the individual (and accumulated income of the trust), and the state will receive all amounts remaining in the trust upon the death of the individual up to the amount equal to the total medical assistance paid on behalf of the individual. For disposition of trust amounts pursuant to Iowa Code sections 633C.1 to 633C.5, the average statewide charges and Medicaid rates are updated annually and shall be published on the department’s website.  c.  A trust containing the assets of an individual who is disabled (as defined in 1614(a)(3) of the Social Security Act) that meets the following conditions:  (1)  The trust is established and managed by a nonprofit association.  (2)  A separate account is maintained for each beneficiary of the trust, but, for purposes of investment and management of funds, the trust pools these accounts.  (3)  Accounts in the trust are established solely for the benefit of individuals who are disabled (as defined in 1614(a)(3) of the Social Security Act) by the parent, grandparent, or legal guardian of the individuals, by the individuals or by a court.  (4)  To the extent that amounts remaining in the beneficiary’s account upon death of the beneficiary are not retained by the trust, the trust pays to the state from the remaining amounts in the account an amount equal to the total amount of medical assistance paid on behalf of the beneficiary.This rule is intended to implement Iowa Code section 249A.4.Related ARC(s): 7834B, 8898B, 9582B, 0192C, 0822C, 0821C, 1484C, 1483C, 2027C, 2605C, 3182C, 3183C, 3869C, 3870C, 4572C441—75.25(249A)  Definitions.  Unless otherwise specified, the definitions in this rule shall apply to 441—Chapters 75 through 85 and 88.
    "Aged" shall mean a person 65 years of age or older.
    "Applicant" shall mean a person who is requesting assistance, including recertification under the medically needy program, on the person’s own behalf or on behalf of another person. This also includes parents living in the home with the children and the nonparental relative who is requesting assistance for the children.
    "Blind" shall mean a person with central visual acuity of 20/200 or less in the better eye with use of corrective lens or visual field restriction to 20 degrees or less.
    "Break in assistance" for medically needy shall mean the lapse of more than three months from the end of the medically needy certification period to the beginning of the next current certification period.
    "Central office" shall mean the state administrative office of the department of human services.
    "Certification period" for medically needy shall mean the period of time not to exceed two consecutive months in which a person is conditionally eligible.
    "Client" shall mean all of the following:
    1. A Medicaid applicant;
    2. A Medicaid member;
    3. A person who is conditionally eligible for Medicaid; and
    4. A person whose income or assets are considered in determining eligibility for an applicant or member.
    "CMAP-related medically needy" shall mean those individuals under the age of 21 who would be eligible for the child medical assistance program except for excess income or resources.
    "Community spouse" shall mean a spouse of an institutionalized spouse for the purposes of rules 441—75.5(249A), 441—75.16(249A), and 441—76.10(249A).
    "Conditionally eligible" shall mean that a person has completed the application process and has been assigned a medically needy certification period and spenddown amount but has not met the spenddown amount for the certification period or has been assigned a monthly premium but has not yet paid the premium for that month.
    "Coverage group" shall mean a group of persons who meet certain common eligibility requirements.
    "Department" shall mean the Iowa department of human services.
    "Disabled" shall mean a person who is unable to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which has lasted or is expected to last for a continuous period of not less than 12 months from the date of application.
    "FMAP-related medically needy" shall mean those persons who would be eligible for the family medical assistance program except for excess income or resources.
    "Health insurance" shall mean protection which provides payment of benefits for covered sickness or injury.
    "Incurred medical expenses" for medically needy shall mean (1) medical bills paid by a client, responsible relative, or state or political subdivision program other than Medicaid during the retroactive certification period or the certification period, or (2) unpaid medical expenses for which the client or responsible relative remains obligated.
    "Institutionalized person" shall mean a person who is an inpatient in a nursing facility or a Medicare-certified skilled nursing facility, who is an inpatient in a medical institution and for whom payment is made based on a level of care provided in a nursing facility, or who is a person described in 75.1(18) for the purposes of rule 441—75.5(249A).
    "Institutionalized spouse" shall mean a married person living in a medical institution, or nursing facility, or home- and community-based waiver setting who is likely to remain living in these circumstances for at least 30 consecutive days, and whose spouse is not in a medical institution or nursing facility for the purposes of rules 441—75.5(249A), 441—75.16(249A), and 441—76.10(249A).
    "Local office" shall mean the county office of the department of human services or the mental health institute or hospital school.
    "Medically needy income level (MNIL)" shall mean 133 1/3 percent of the schedule of basic needs based on family size. (See subrule 75.58(2).)
    "Member" shall mean a person who has been determined eligible for medical assistance under rule 441—75.1(249A). For the medically needy program, “member” shall mean a medically needy person who has income at or less than the medically needy income level (MNIL) or who has reduced countable income to the MNIL during the certification period through spenddown. “Member” may be used interchangeably with “recipient.” This definition does not apply to the phrase “household member.”
    "Necessary medical and remedial services" for medically needy shall mean medical services recognized by law which are currently covered under the Iowa Medicaid program.
    "Noncovered Medicaid services" for medically needy shall mean medical services that are not covered under Medicaid because the provider was not enrolled in Medicaid, the services are ones which are otherwise not covered under Medicaid, the bill is for a responsible relative who is not in the Medicaid-eligible group or the bill is for services delivered before the start of a certification period.
    "Nursing facility services" shall mean the level of care provided in a medical institution licensed for nursing services or skilled nursing services for the purposes of rule 441—75.23(249A).
    "Obligated medical expense" for medically needy shall mean a medical expense for which the client or responsible relative continues to be legally liable.
    "Ongoing eligibility" for medically needy shall mean that eligibility continues for an SSI-related, CMAP-related, or FMAP-related medically needy person with a zero spenddown.
    "Pay and chase" shall mean that the state pays the total amount allowed under the agency’s payment schedule and then seeks reimbursement from the liable third party. The pay and chase provision applies to Medicaid claims for prenatal care, for preventive pediatric services, and for all services provided to a person for whom there is court-ordered medical support.
    "Payee" refers to an SSI payee as defined in Iowa Code subsections 633.33(7) and 633.3(20).
    "Recertification" in the medically needy coverage group shall mean establishing a new certification period when the previous period has expired and there has not been a break in assistance.
    "Recipient" shall mean a person who is receiving assistance including receiving assistance for another person.
    "Responsible relative" for medically needy shall mean a spouse, parent, or stepparent living in the household of the client.
    "Retroactive certification period" for medically needy shall mean one, two, or three calendar months prior to the date of application, as provided in 441—subrule 76.13(3). The retroactive certification period begins with the first month Medicaid-covered services were received and continues to the end of the month immediately prior to the month of application.
    "Retroactive period" shall mean the three or fewer calendar months immediately preceding the month in which an application is filed, pursuant to 441—subrule 76.13(3).
    "Spenddown" shall mean the process by which a medically needy person obligates excess income for allowable medical expenses to reduce income to the appropriate MNIL.
    "SSI-related" shall mean those persons whose eligibility is derived from regulations governing the supplemental security income (SSI) program except that income shall be considered prospectively.
    "SSI-related medically needy" shall mean those persons whose eligibility is derived from regulations governing the supplemental security income (SSI) program except for income or resources.
    "Supply" shall mean the requested information is received by the department by the specified due date.
    "Transfer of assets" shall mean transfer of resources or income for less than fair market value for the purposes of rule 441—75.23(249A). For example, a transfer of resources or income could include establishing a trust, contributing to a charity, removing a name from a resource or income, or reducing ownership interest in a resource or income.
    "Unborn child" shall include an unborn child during the entire term of pregnancy.
    This rule is intended to implement Iowa Code sections 249A.3 and 249A.4.
    Related ARC(s): 7935B, 2361C, 3353C, 3549C, 4208C441—75.26(249A)  References to the family investment program.  Rescinded IAB 10/8/97, effective 12/1/97.441—75.27(249A)  AIDS/HIV settlement payments.  The following payments are exempt as income and resources when determining eligibility for or the amount of Medicaid benefits under any coverage group if the payments are kept in a separate, identifiable account:  75.27(1)    Class settlement payments.  Payments made from any fund established pursuant to a class settlement in the case of Susan Walker v.Bayer Corporation, et al., 96-C-5024 (N.D. Ill.) are exempt.  75.27(2)    Other settlement payments.  Payments made pursuant to a release of all claims in a case that is entered into in lieu of the class settlement referred to in subrule 75.27(1) and that is signed by all affected parties in the cases on or before the later of December 31, 1997, or the date that is 270 days after the date on which the release is first sent to the person (or the legal representative of the person) to whom payment is to be made are exempt.This rule is intended to implement Iowa Code sections 249A.3 and 249A.4.441—75.28(249A)  Recovery.    75.28(1)    Definitions.  
    "Administrative overpayment" means medical assistance incorrectly paid to or for the client because of continuing assistance during the appeal process or allowing a deduction for the Medicare Part B premium in determining client participation while the department arranges to pay the Medicare premium directly.
    "Agency error" means medical assistance incorrectly paid to or for the client because of action attributed to the department as the result of one or more of the following circumstances:
    1. Misfiling or loss of forms or documents.
    2. Errors in typing or copying.
    3. Computer input errors.
    4. Mathematical errors.
    5. Failure to determine eligibility correctly or to certify assistance in the correct amount when all essential information was available to the department.
    6. Failure to make prompt revisions in medical payment following changes in policies requiring the changes as of a specific date.
    "Client" means a current or former Medicaid member.
    "Client error" means medical assistance incorrectly paid to or for the client because the client or client’s representative failed to disclose information, or gave false or misleading statements, oral or written, regarding the client’s income, resources, or other eligibility and benefit factors. “Client error” also means assistance incorrectly paid to or for the client because of failure by the client or client’s representative to timely report as defined in rule 441—76.15(249A).
    "Department" means the department of human services.
    "Premiums paid for medical assistance" means monthly premiums assessed to a member or household for Medicaid, IowaCare or the Iowa Health and Wellness Plan coverage.
      75.28(2)    Amount subject to recovery.  The department shall recover from a client all Medicaid funds incorrectly expended to or on behalf of the client and all unpaid premiums assessed by the department for medical assistance. The incorrect expenditures or unpaid premiums may result from client or agency error or administrative overpayment.  75.28(3)    Notification.  All clients shall be promptly notified on Form 470-2891, Notice of Medical Assistance Overpayment, when it is determined that assistance was incorrectly expended or when assessed premiums are unpaid.  a.  Notification of incorrect expenditures shall include:  (1)  For whom assistance was paid;  (2)  The period during which assistance was incorrectly paid;  (3)  The amount of assistance subject to recovery; and  (4)  The reason for the incorrect expenditure.  b.  Notification of unpaid premiums shall include:  (1)  The amount of the premium; and  (2)  The month covered by the medical assistance premium.  75.28(4)    Source of recovery.  Recovery shall be made from the client or from parents of children under the age of 21 when the parents completed the application and had responsibility for reporting changes. Recovery may come from income, resources, the estate, income tax refunds, and lottery winnings of the client.  75.28(5)    Repayment.  The repayment of incorrectly expended Medicaid funds shall be made to the department. However, repayment of funds incorrectly paid to a nursing facility, a Medicare-certified skilled nursing facility, a psychiatric medical institution for children, an intermediate care facility for persons with an intellectual disability, or mental health institute enrolled as an inpatient psychiatric facility may be made by the client to the facility. The department shall then recover the funds from the facility through a vendor adjustment.  75.28(6)    Appeals.  The client shall have the right to appeal the amount of funds subject to recovery under the provisions of 441—Chapter 7.  75.28(7)    Estate recovery.  Medical assistance, including the amount the state paid to a managed care organization (MCO) for provision of medical services, also called capitation fees, is subject to recovery from the estate of a Medicaid member, the estate of the member’s surviving spouse, or the estate of the member’s surviving child as provided in this subrule. Effective January 1, 2010, medical assistance that has been paid for Medicare cost sharing or for benefits described in Section 1902(a)(10)(E) of the Social Security Act is not subject to recovery. All assets included in the estate of the member, the surviving spouse, or the surviving child are subject to probate for the purposes of medical assistance estate recovery pursuant to Iowa Code section 249A.53(2)“d.” The classification of the debt is defined at Iowa Code section 633.425(7).  a.    Definitions.  
    "Capitated payment/rate" means a monthly payment to the contractor on behalf of each member for the provision of health services under the contract. Payment is made regardless of whether the member receives services during the month.
    "Estate." For the purpose of this subrule, the “estate” of a Medicaid member, a surviving spouse, or a surviving child shall include all real property, personal property, or any other asset in which the member, spouse, or surviving child had any legal title or interest at the time of death, or at the time a child reaches the age of 21, to the extent of that interest. An estate includes, but is not limited to, interest in jointly held property, retained life estates, and interests in trusts.
    "Managed care organization" means an entity that (1) is under contract with the department to provide services to Medicaid recipients and (2) meets the definition of “health maintenance organization” as defined in Iowa Code section 514B.1.
      b.    Debt due for member 55 years of age or older.  Receipt of medical assistance when a member is 55 years of age or older creates a debt due to the department from the member’s estate upon the member’s death for all medical assistance provided on the member’s behalf on or after July 1, 1994.  c.    Debt due for member under the age of 55 in a medical institution.    (1)  Receipt of medical assistance creates a debt due to the department from the member’s estate upon the member’s death for all medical assistance provided on the member’s behalf on or after July 1, 1994, when the member:
    1. Is under the age of 55; and
    2. Is a resident of a nursing facility, an intermediate care facility for persons with an intellectual disability, or a mental health institute; and
    3. Cannot reasonably be expected to be discharged and return home.
      (2)  If the member is discharged from the facility and returns home before staying six consecutive months, no debt will be assessed for medical assistance payments made on the member’s behalf for the time in the institution.  (3)  If the member remains in the facility for six consecutive months or longer or dies before staying six consecutive months, the department shall presume that the member cannot or could not reasonably be expected to be discharged and return home and a debt due shall be established. The department shall notify the member of the presumption and the establishment of a debt due.
      d.    Request for a determination of ability to return home.  Upon receipt of a notice of the establishment of a debt due based on the presumption that the member cannot return home, the member or someone acting on the member’s behalf may request that the department determine whether the member can or could reasonably have been expected to return home.  (1)  When a written request is made within 30 days of the notice that a debt due will be established, no debt due shall be established until the department has made a decision on the member’s ability to return home. If the determination is that there is or was no ability to return home, a debt due shall be established for all medical assistance as of the date of entry into the institution.  (2)  When a written request is made more than 30 days after the notice that a debt due will be established, a debt due will be established for medical assistance provided before the request even if the determination is that the member can or could have returned home.  e.    Determination of ability to return home.  When the member or someone acting on the member’s behalf requests that the department determine if the member can or could have returned home, the determination shall be made by the Iowa Medicaid enterprise (IME) medical services unit.  (1)  The IME medical services unit cannot make a determination until the member has been in an institution at least six months or after the death of the member, whichever is earlier. The IME medical services unit will notify the member or the member’s representative and the department of the determination.  (2)  If the determination is that the member can or could return home, the IME medical services unit shall establish the date the return is expected or could have been expected to occur.  (3)  If the determination is that the member cannot or could not return home, a debt due will be established unless the member or the member’s representative asks for a reconsideration of the decision. The IME medical services unit will notify the member or the member’s representative and the department of the reconsideration decision.  (4)  If the reconsideration decision is that the member cannot or could not return home, a debt due will be established against the member unless the decision is appealed pursuant to 441—Chapter 7. The appeal decision will determine the final outcome for the establishment of a debt due and the period when the debt is established.  f.    Debt collection.    (1)  A nursing facility participating in the medical assistance program shall notify the IME revenue collection unit upon the death of a member residing in the facility by submitting Form 470-4331, Estate Recovery Program Nursing Home Referral.  (2)  Upon receipt of Form 470-4331 or a report of a member’s death through other means, the IME revenue collection unit will use Form 470-4339, Medical Assistance Debt Response, to request a statement of the member’s assets from the member’s personal representative. The representative shall sign and return Form 470-4339 indicating whether assets remain and, if so, what the assets are and what higher priority expenses exist. Exception: The procedures in this subparagraph are not necessary when a probate estate has been opened, because probate procedures provide for an inventory, an accounting, and a final report of the estate.  g.    Waiving the collection of the debt.    (1)  The department shall waive the collection of the debt created under this subrule from the estate of the member to the extent that collection of the debt would result in either of the following:
    1. Reduction in the amount received from the member’s estate by a surviving spouse or by a surviving child who is under the age of 21, blind, or permanently and totally disabled at the time of the member’s death.
    2. Creation of an undue hardship for the person seeking a waiver of estate recovery. Undue hardship exists when total household income is less than 200 percent of the poverty level for a household of the same size, total household resources do not exceed $10,000, and application of estate recovery would result in deprivation of food, clothing, shelter, or medical care such that life or health would be endangered. For this purpose, “income” and “resources” shall be defined as being under the family investment program.
      (2)  To apply for a waiver of estate recovery due to undue hardship, the person shall provide a written statement and supporting verification to the department within 30 days of the notice of estate recovery pursuant to Iowa Code section 249A.53(2).  (3)  The department shall determine whether undue hardship exists on a case-by-case basis. Appeals of adverse decisions regarding an undue hardship determination may be filed in accordance with 441—Chapter 7.
      h.    Amount waived.  If collection of all or part of a debt is waived pursuant to paragraph 75.28(7)“g,” to the extent that the person received the member’s estate, the amount waived shall be a debt due from the following:  (1)  The estate of the member’s surviving spouse, upon the death of the spouse.  (2)  The estate of the member’s surviving child who is blind or has a disability, upon the death of the child.  (3)  A surviving child who was under 21 years of age at the time of the member’s death, when the child reaches the age of 21.  (4)  The estate of a surviving child who was under 21 years of age at the time of the member’s death, if the child dies before reaching the age of 21.  (5)  The hardship waiver recipient, when the hardship no longer exists.  (6)  The estate of the recipient of the undue hardship waiver, at the time of death of the hardship waiver recipient.  i.    Impact of asset disregard on debt due.  The estate of a member who is eligible for medical assistance under subrule 75.5(5) shall not be subject to a claim for medical assistance paid on the member’s behalf up to the amount of the assets disregarded by asset disregard. Medical assistance paid on behalf of the member before these conditions shall be recovered from the estate, regardless of the member’s having purchased precertified or approved insurance.  j.    Interest on debt.  Interest shall accrue on a debt due under this subrule at the rate provided pursuant to Iowa Code section 535.3, beginning six months after the death of a Medicaid member, the surviving spouse, or the surviving child, or upon the child’s reaching the age of 21.  k.    Reimbursement to county.  If a county reimburses the department for medical assistance provided under this subrule and the amount of medical assistance is subsequently repaid through a medical assistance income trust or a medical assistance special needs trust as defined in Iowa Code chapter 633C, the department shall reimburse the county on a proportionate basis.
    Related ARC(s): 1134C, 2361C441—75.29(249A)  Investigation by quality control or the department of inspections and appeals.  An applicant or member shall cooperate with the department when the applicant’s or member’s case is selected by quality control or the department of inspections and appeals for verification of eligibility unless the investigation revolves solely around the circumstances of a person whose income and resources do not affect medical assistance eligibility. (See department of inspections and appeals rules in 481—Chapter 72.) Failure to cooperate shall serve as a basis for denial of an application or cancellation of medical assistance unless the Medicaid eligibility is determined by the Social Security Administration. Once a person’s eligibility is denied or canceled for failure to cooperate, the person may reapply but shall not be determined eligible until cooperation occurs.Related ARC(s): 1134C441—75.30(249A)  Member lock-in.  Rescinded ARC 2361C, IAB 1/6/16, effective 1/1/16.441—75.31    Reserved.441—75.32    Reserved.441—75.33    Reserved.441—75.34    Reserved.441—75.35    Reserved.441—75.36    Reserved.441—75.37    Reserved.441—75.38    Reserved.441—75.39    Reserved.441—75.40    Reserved.441—75.41    Reserved.441—75.42    Reserved.441—75.43    Reserved.441—75.44    Reserved.441—75.45    Reserved.441—75.46    Reserved.441—75.47    Reserved.441—75.48    Reserved.441—75.49    Reserved.DIVISION IIELIGIBILITY FACTORS SPECIFIC TO COVERAGE GROUPS RELATED TOTHE FAMILY MEDICAL ASSISTANCE PROGRAM (FMAP)441—75.50(249A)  Definitions.  The following definitions apply to this division in addition to the definitions in rule 441—75.25(249A).
    "Applicant" shall mean a person who is requesting assistance on the person’s own behalf or on behalf of another person, including recertification under the medically needy program. This also includes parents living in the home with the children and the nonparental relative who is requesting assistance for the children.
    "Application period" means the months beginning with the month in which the application is considered to be filed, through and including the month in which an eligibility determination is made.
    "Assistance unit" includes any person whose income is considered when determining eligibility.
    "Bona fide offer" means an actual or genuine offer which includes a specific wage or a training opportunity at a specified place when used to determine whether the parent has refused an offer of training or employment.
    "Central office" shall mean the state administrative office of the department of human services.
    "Change in income" means a permanent change in hours worked or rate of pay, any change in the amount of unearned income, or the beginning or ending of any income.
    "Change in work expenses" means a permanent change in the cost of dependent care or the beginning or ending of dependent care.
    "Department" shall mean the Iowa department of human services.
    "Dependent" means an individual who can be claimed by another individual as a dependent for federal income tax purposes.
    "Dependent child" "dependent children" means a child or children who meet the nonfinancial eligibility requirements of the applicable FMAP-related coverage group.
    "Income in-kind" is any gain or benefit which is not in the form of money payable directly to the eligible group including nonmonetary benefits, such as meals, clothing, and vendor payments. Vendor payments are money payments which are paid to a third party and not to the eligible group.
    "Initial two months" means the first two consecutive months for which eligibility is granted.
    "Medical institution," when used in this division, shall mean a facility which is organized to provide medical care, including nursing and convalescent care, in accordance with accepted standards as authorized by state law and as evidenced by the facility’s license. A medical institution may be public or private. Medical institutions include the following:
    1. Hospitals.
    2. Extended care facilities (skilled nursing).
    3. Intermediate care facilities.
    4. Mental health institutions.
    5. Hospital schools.
    "Needy specified relative" means a nonparental specified relative, listed in 75.55(1), who meets all the eligibility requirements of the FMAP coverage group, listed in 75.1(14).
    "Nonrecurring lump sum unearned income" means a payment in the nature of a windfall, for example, an inheritance, an insurance settlement for pain and suffering, an insurance death benefit, a gift, lottery winnings, or a retroactive payment of benefits such as social security, job insurance or workers’ compensation.
    "Parent" means a legally recognized parent, including an adoptive parent, or a biological father if there is no legally recognized father.
    "Prospective budgeting" means the determination of eligibility and the amount of assistance for a calendar month based on the best estimate of income and circumstances which will exist in that calendar month.
    "Recipient" means a person for whom Medicaid is received as well as parents living in the home with the eligible children and other specified relatives as defined in subrule 75.55(1) who are receiving Medicaid for the children. Unless otherwise specified, a person is not a recipient for any month in which the assistance issued for that person is subject to recoupment because the person was ineligible.
    "Schedule of needs" means the total needs of a group as determined by the schedule of living costs, described at subrule 75.58(2).
    "Stepparent" means a person who is not the parent of the dependent child, but is the legal spouse of the dependent child’s parent by ceremonial or common-law marriage.
    "Unborn child" shall include an unborn child during the entire term of the pregnancy.
    "Uniformed service" means the Army, Navy, Air Force, Marine Corps, Coast Guard, National Oceanographic and Atmospheric Administration, or Public Health Service of the United States.
    441—75.51(249A)  Reinstatement of eligibility.  Rescinded IAB 2/10/10, effective 3/1/10.441—75.52(249A)  Continuing eligibility.    75.52(1)    Reviews.  Eligibility factors shall be reviewed at least annually for the FMAP-related programs. Reviews shall be conducted using information contained in and verification supplied with the review form specified in subrule 75.52(3).  75.52(2)    Additional reviews.  A redetermination of specific eligibility factors shall be made when:  a.  The member reports a change in circumstances (for example, a change in income, as defined at rule 441—75.50(249A)), or  b.  A change in the member’s circumstances comes to the attention of a staff member.  75.52(3)    Forms.    a.  Information for the annual review shall be submitted on Form 470-2881, 470-2881(M), 470-2881(S), or 470-2881(MS), Review/Recertification Eligibility Document (RRED), with the following exceptions:  (1)  When the client has completed Form 470-0462 or 470-0466 (Spanish), Health and Financial Support Application, for another purpose, this form may be used as the review document for the annual review.  (2)  Information for recertification of family medical assistance-related medically needy shall be submitted on Form 470-3118 or 470-3118(S), Medicaid Review.  b.  The department shall supply the review form to the client as needed, or upon request, and shall pay the cost of postage to return the form.  (1)  When the review form is issued in the department’s regular end-of-month mailing, the client shall return the completed form to the department by the fifth calendar day of the following month.  (2)  When the review form is not issued in the department’s regular end-of-month mailing, the client shall return the completed form to the department by the seventh day after the date the form is mailed by the department.  (3)  A copy of a review form received by fax or electronically shall have the same effect as an original form.  c.  The review information for foster children or children in subsidized adoption or subsidized guardianship shall be submitted on Form 470-2914, Foster Care, Adoption, and Guardianship Medicaid Review.  75.52(4)    Client responsibilities.  For the purposes of this subrule, “clients” shall include persons who received assistance subject to recoupment because the persons were ineligible.  a.  The client shall cooperate by giving complete and accurate information needed to establish eligibility.  b.  The client shall complete the required review form when requested by the department in accordance with subrule 75.52(3). If the department does not receive a completed form, assistance shall be canceled. A completed form is one that has all items answered, is signed, is dated, and is accompanied by verification as required in paragraphs 75.57(1)“f” and 75.57(2)“l.”  c.  The client shall report any change in the following circumstances at the annual review or upon the addition of an individual to the eligible group:  (1)  Income from all sources, including any change in care expenses.  (2)  Resources.  (3)  Members of the household.  (4)  School attendance.  (5)  A stepparent recovering from an incapacity.  (6)  Change of mailing or living address.  (7)  Payment of child support.  (8)  Receipt of a social security number.  (9)  Payment for child support, alimony, or dependents as defined in paragraph 75.57(8)“b.”  (10)  Health insurance premiums or coverage.  d.  All clients shall timely report any change in the following circumstances at any time:  (1)  Members of the household.  (2)  Change of mailing or living address.  (3)  Sources of income.  (4)  Health insurance premiums or coverage.  e.  Clients described at subrule 75.1(35) shall also timely report any change in income from any source and any change in care expenses at any time.  f.  A report shall be considered timely when made within ten days from the date:  (1)  A person enters or leaves the household.  (2)  The mailing or living address changes.  (3)  A source of income changes.  (4)  A health insurance premium or coverage change is effective.  (5)  Of any change in income.  (6)  Of any change in care expenses.  g.  When a change is not reported as required in paragraphs 75.52(4)“c” through “e,” any excess Medicaid paid shall be subject to recovery.  h.  When a change in any circumstance is reported, its effect on eligibility shall be evaluated and eligibility shall be redetermined, if appropriate, regardless of whether the report of the change was required in paragraphs 75.52(4)“c” through “e.”  75.52(5)    Effective date.  After assistance has been approved, eligibility for continuing assistance shall be effective as of the first of each month. Any change affecting eligibility reported during a month shall be effective the first day of the next calendar month, subject to timely notice requirements at rule 441—7.6(217) for any adverse actions.  a.  When the change creates ineligibility, eligibility under the current coverage group shall be canceled and an automatic redetermination of eligibility shall be completed in accordance with rule 441—76.11(249A).  b.  Rescinded IAB 10/4/00, effective 10/1/00.  c.  When an individual included in the eligible group becomes ineligible, that individual’s Medicaid shall be canceled effective the first of the next month unless the action must be delayed due to timely notice requirements at rule 441—7.6(217).Related ARC(s): 8260B, 8500B441—75.53(249A)  Iowa residency policies specific to FMAP and FMAP-related coverage groups.  Notwithstanding the provisions of rule 441—75.10(249A), the following rules shall apply when determining eligibility for persons under FMAP or FMAP-related coverage groups.  75.53(1)    Definition of resident.  A resident of Iowa is one:  a.  Who is living in Iowa voluntarily with the intention of making that person’s home there and not for a temporary purpose. A child is a resident of Iowa when living there on other than a temporary basis. Residence may not depend upon the reason for which the individual entered the state, except insofar as it may bear upon whether the individual is there voluntarily or for a temporary purpose; or   b.  Who, at the time of application, is living in Iowa, is not receiving assistance from another state, and entered Iowa with a job commitment or seeking employment in Iowa, whether or not currently employed. Under this definition the child is a resident of the state in which the specified relative is a resident.  75.53(2)    Retention of residence.  Residence is retained until abandoned. Temporary absence from Iowa, with subsequent returns to Iowa, or intent to return when the purposes of the absence have been accomplished does not interrupt continuity of residence.  75.53(3)    Suitability of home.  The home shall be deemed suitable until the court has ruled it unsuitable and, as a result of such action, the child has been removed from the home.  75.53(4)    Absence from the home.    a.  An individual who is absent from the home shall not be included in the eligible group, except as described in paragraph “b.”  (1)  A parent who 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 is considered absent from the home.  (2)  A parent whose absence from the home is due solely to a pattern of employment is not considered to be absent.  (3)  A parent whose absence is occasioned solely by reason of the performance of active duty in the uniformed services of the United States is considered absent from the home. “Uniformed service” means the Army, Navy, Air Force, Marine Corps, Coast Guard, National Oceanographic and Atmospheric Administration, or Public Health Service of the United States.  b.  The needs of an individual who is temporarily out of the home are included in the eligible group if otherwise eligible. A temporary absence exists in the following circumstances:  (1)  An individual is anticipated to be in the medical institution for less than a year, as verified by a physician’s statement. Failure to return within one year from the date of entry into the medical institution will result in the individual’s needs being removed from the eligible group.  (2)  A child is out of the home to secure education or training as defined in paragraph 75.54(1)“b” as long as the child remains a dependent.  (3)  A parent or specified relative is temporarily out of the home to secure education or training and was in the eligible group before leaving the home to secure education or training. For this purpose, “education or training” means any academic or vocational training program that prepares a person for a specific professional or vocational area of employment.  (4)  An individual is out of the home for reasons other than reasons in subparagraphs 75.53(4)“b”(1) through (3) and intends to return to the home within three months. Failure to return within three months from the date the individual left the home will result in the individual’s needs being removed from the eligible group.Related ARC(s): 0579C441—75.54(249A)  Eligibility factors specific to child.    75.54(1)    Age.  Unless otherwise specified at rule 441—75.1(249A), Medicaid shall be available to a needy child under the age of 18 years without regard to school attendance.  a.  A child is eligible for the entire month in which the child’s eighteenth birthday occurs, unless the birthday falls on the first day of the month.  b.  Medicaid shall also be available to a needy child aged 18 years who is a full-time student in a secondary school, or in the equivalent level of vocational or technical training, and who is reasonably expected to complete the program before reaching the age of 19 if the following criteria are met.  (1)  A child shall be considered attending school full-time when enrolled or accepted in a full-time (as certified by the school or institute attended) elementary, secondary or the equivalent level of vocational or technical school or training leading to a certificate or diploma. Correspondence school is not an allowable program of study.  (2)  A child shall also be considered to be in regular attendance in months when the child is not attending because of an official school or training program vacation, illness, convalescence, or family emergency. A child meets the definition of regular school attendance until the child has been officially dropped from the school rolls.  (3)  When a child’s education is temporarily interrupted pending adjustment of an education or training program, exemption shall be continued for a reasonable period of time to complete the adjustment.  75.54(2)    Residing with a relative.  The child shall be living in the home of one of the relatives specified in subrule 75.55(1). When the mother intends to place her child for adoption shortly after birth, the child shall be considered as living with the mother until the time custody is actually relinquished.  a.  Living with relatives implies primarily the existence of a relationship involving an accepted responsibility on the part of the relative for the child’s welfare, including the sharing of a common household.  b.  Home is the family setting maintained or in the process of being established as evidenced by the assumption and continuation of responsibility for the child by the relative.  75.54(3)    Deprivation of parental care and support.  Rescinded IAB 11/1/00, effective 1/1/01.  75.54(4)    Continuous eligibility for children.  Rescinded IAB 11/5/08, effective 11/1/08.441—75.55(249A)  Eligibility factors specific to specified relatives.    75.55(1)    Specified relationship.    a.  A child may be considered as meeting the requirement of living with a specified relative if the child’s home is with one of the following or with a spouse of the relative even though the marriage is terminated by death or divorce:Father or adoptive father.Mother or adoptive mother.Grandfather or grandfather-in-law, meaning the subsequent husband of the child’s natural grandmother, i.e., stepgrandfather or adoptive grandfather.Grandmother or grandmother-in-law, meaning the subsequent wife of the child’s natural grandfather, i.e., stepgrandmother or adoptive grandmother.Great-grandfather or great-great-grandfather.Great-grandmother or great-great-grandmother.Stepfather, but not his parents.Stepmother, but not her parents.Brother, brother-of-half-blood, stepbrother, brother-in-law or adoptive brother.Sister, sister-of-half-blood, stepsister, sister-in-law or adoptive sister.Uncle or aunt, of whole or half blood.Uncle-in-law or aunt-in-law.Great uncle or great-great-uncle.Great aunt or great-great-aunt.First cousins, nephews, or nieces.  b.  A relative of the putative father can qualify as a specified relative if the putative father has acknowledged paternity by the type of written evidence on which a prudent person would rely.  75.55(2)    Liability of relatives.  All appropriate steps shall be taken to secure support from legally liable persons on behalf of all persons in the eligible group, including the establishment of paternity as provided in rule 441—75.14(249A).  a.  When necessary to establish eligibility, the department shall make the initial contact with the absent parent at the time of application. Subsequent contacts may be made by the child support recovery unit.  b.  When contact with the family or other sources of information indicates that relatives other than parents and spouses of the eligible children are contributing toward the support of members of the eligible group, have contributed in the past, or are of such financial standing they might reasonably be expected to contribute, the department shall contact these persons to verify current contributions or arrange for contributions on a voluntary basis.Related ARC(s): 8785B441—75.56(249A)  Resources.    75.56(1)    Limitation.  Unless otherwise specified, a client may have the following resources and be eligible for the family medical assistance program (FMAP) or FMAP-related programs. Any resource not specifically exempted shall be counted toward the applicable resource limit when determining eligibility for adults. All resources shall be disregarded when determining eligibility for children.  a.  A homestead without regard to its value. A mobile home or similar shelter shall be considered as a homestead when it is occupied by the client. Temporary absence from the homestead with a defined purpose for the absence and with intent to return when the purpose of the absence has been accomplished shall not be considered to have altered the exempt status of the homestead. Except as described at paragraph 75.56(1)“n” or “o,” the net market value of any other real property shall be considered with personal property.  b.  Household goods and personal effects without regard to their value. Personal effects are personal or intimate tangible belongings of an individual, especially those that are worn or carried on the person, which are maintained in one’s home, and include clothing, books, grooming aids, jewelry, hobby equipment, and similar items.  c.  Life insurance which has no cash surrender value. The owner of the life insurance policy is the individual paying the premium on the policy with the right to change the policy as the individual sees fit.  d.  One motor vehicle per household. If the household includes more than one adult or working teenaged child whose resources must be considered as described in subrule 75.56(2), an equity not to exceed a value of $3,000 in one additional motor vehicle shall be disregarded for each additional adult or working teenaged child.  (1)  The disregard for an additional motor vehicle shall be allowed when a working teenager is temporarily absent from work.  (2)  The equity value of any additional motor vehicle in excess of $3,000 shall be counted toward the resource limit in paragraph 75.56(1)“e.” When a motor vehicle is modified with special equipment for the handicapped, the special equipment shall not increase the value of the motor vehicle.  (3)  Beginning July 1, 1994, and continuing in succeeding state fiscal years, the motor vehicle equity value to be disregarded shall be increased by the latest increase in the consumer price index for used vehicles during the previous state fiscal year.  e.  A reserve of other property, real or personal, not to exceed $2,000 for applicant assistance units and $5,000 for member assistance units. Exception: Applicant assistance units that contain at least one person who was a Medicaid member in Iowa in the month before the month of application are subject to the $5,000 limit. Resources of the assistance unit shall be determined in accordance with persons considered, as described at subrule 75.56(2).  f.  Money which is counted as income for the month and that part of lump-sum income defined at paragraph 75.57(9)“c” reserved for the current or future month’s income.  g.  Payments which are exempted for consideration as income and resources under subrule 75.57(6).  h.  An equity not to exceed $1,500 in one funeral contract or burial trust for each member of the eligible group. Any amount in excess of $1,500 shall be counted toward resource limits unless it is established that the funeral contract or burial trust is irrevocable.  i.  One burial plot for each member of the eligible group. A burial plot is defined as a conventional gravesite, crypt, mausoleum, urn, or other repository which is customarily and traditionally used for the remains of a deceased person.  j.  Settlements for payment of medical expenses.  k.  Life estates.  l.  Federal or state earned income tax credit payments in the month of receipt and the following month, regardless of whether these payments are received with the regular paychecks or as a lump sum with the federal or state income tax refund.  m.  The balance in an individual development account (IDA), including interest earned on the IDA.  n.  An equity not to exceed $10,000 for tools of the trade or capital assets of self-employed households.When the value of any resource is exempted in part, that portion of the value which exceeds the exemption shall be considered in calculating whether the eligible group’s property is within the reserve defined in paragraph “e.”  o.  Nonhomestead property that produces income consistent with the property’s fair market value.  75.56(2)    Persons considered.    a.  Resources of persons in the eligible group shall be considered in establishing property limits.  b.  Resources of the parent who is living in the home with the eligible children but who is not eligible for Medicaid shall be considered in the same manner as if the parent were eligible for Medicaid.  c.  Resources of the stepparent living in the home shall not be considered when determining eligibility of the eligible group, with one exception: The resources of a stepparent included in the eligible group shall be considered in the same manner as a parent.  d.  The resources of supplemental security income (SSI) members shall not be counted in establishing property limitations. When property is owned by both the SSI beneficiary and a Medicaid member in another eligible group, each shall be considered as having a half interest in order to determine the value of the resource, unless the terms of the deed or purchase contract clearly establish ownership on a different proportional basis.  e.  The resources of a nonparental specified relative who elects to be included in the eligible group shall be considered in the same manner as a parent.  75.56(3)    Homestead defined.  The homestead consists of the house, used as a home, and may contain one or more contiguous lots or tracts of land, including buildings and appurtenances. When within a city plat, it shall not exceed ½ acre in area. When outside a city plat it shall not contain, in the aggregate, more than 40 acres. When property used as a home exceeds these limitations, the equity value of the excess property shall be determined in accordance with subrule 75.56(5).  75.56(4)    Liquidation.  When proceeds from the sale of resources or conversion of a resource to cash, together with other nonexempted resources, exceed the property limitations, the member is ineligible to receive assistance until the amount in excess of the resource limitation has been expended unless immediately used to purchase a homestead, or reduce the mortgage on a homestead.  a.  Property settlements. Property settlements which are part of a legal action in a dissolution of marriage or palimony suit are considered as resources upon receipt.  b.  Property sold under installment contract. Property sold under an installment contract or held as security in exchange for a price consistent with its fair market value is exempt as a resource. If the price is not consistent with the contract’s fair market value, the resource value of the installment contract is the gross price for which it can be sold or discounted on the open market, less any legal debts, claims, or liens against the installment contract.Payments from property sold under an installment contract are exempt as income as specified in paragraphs 75.57(1)“d” and 75.57(7)“ag.” The portion of any payment received representing principal is considered a resource upon receipt. The interest portion of the payment is considered a resource the month following the month of receipt.  75.56(5)    Net market value defined.  Net market value is the gross price for which property or an item can currently be sold on the open market, less any legal debts, claims, or liens against the property or item.  75.56(6)    Availability.    a.  A resource must be available in order for it to be counted toward resource limitations. A resource is considered available under the following circumstances:  (1)  The applicant or member owns the property in part or in full and has control over it. That is, it can be occupied, rented, leased, sold, or otherwise used or disposed of at the individual’s discretion.  (2)  The applicant or member has a legal interest in a liquidated sum and has the legal ability to make the sum available for support and maintenance.  b.  Rescinded IAB 6/30/99, effective 9/1/99.  c.  When property is owned by more than one person, unless otherwise established, it is assumed that all persons hold equal shares in the property.  d.  When the applicant or member owns nonhomestead property, the property shall be considered exempt for so long as the property is publicly advertised for sale at an asking price that is consistent with its fair market value.  75.56(7)    Damage judgments and insurance settlements.    a.  Payment resulting from damage to or destruction of an exempt resource shall be considered a resource to the applicant or member the month following the month the payment was received. When the applicant or member signs a legal binding commitment no later than the month after the month the payment was received, the funds shall be considered exempt for the duration of the commitment providing the terms of the commitment are met within eight months from the date of commitment.  b.  Payment resulting from damage to or destruction of a nonexempt resource shall be considered a resource in the month following the month in which payment was received.  75.56(8)    Conservatorships.    a.  Conservatorships established prior to February 9, 1994. The department shall determine whether assets from a conservatorship, except one established solely for the payment of medical expenses, are available by examining the language of the order establishing the conservatorship.  (1)  Funds clearly conserved and available for care, support, or maintenance shall be considered toward resource or income limitations.  (2)  When the department worker questions whether the funds in a conservatorship are available, the worker shall refer the conservatorship to the central office. When assets in the conservatorship are not clearly available, central office staff may contact the conservator and request that the funds in the conservatorship be made available for current support and maintenance. When the conservator chooses not to make the funds available, the department may petition the court to have the funds released either partially or in their entirety or as periodic income payments.  (3)  Funds in a conservatorship that are not clearly available shall be considered unavailable until the conservator or court actually makes the funds available.  (4)  Payments received from the conservatorship for basic or special needs are considered income.  b.  Conservatorships established on or after February 9, 1994. Conservatorships established on or after February 9, 1994, shall be treated according to the provisions of paragraphs 75.24(1)“e” and 75.24(2)“b.”  75.56(9)    Not considered a resource.  Inventories and supplies, exclusive of capital assets, that are required for self-employment shall not be considered a resource. Inventory is defined as all unsold items, whether raised or purchased, that are held for sale or use and shall include, but not be limited to, merchandise, grain held in storage and livestock raised for sale. Supplies are items necessary for the operation of the enterprise, such as lumber, paint, and seed. Capital assets are those assets which, if sold at a later date, could be used to claim capital gains or losses for federal income tax purposes. When self-employment is temporarily interrupted due to circumstances beyond the control of the household, such as illness, inventory or supplies retained by the household shall not be considered a resource.441—75.57(249A)  Income.  When determining initial and ongoing eligibility for the family medical assistance program (FMAP) and FMAP-related Medicaid coverage groups, all unearned and earned income, unless specifically exempted, disregarded, deducted for work expenses, or diverted as defined in these rules, shall be considered.
    1. Unless otherwise specified at rule 441—75.1(249A), the determination of initial eligibility is a three-step process. Initial eligibility shall be granted only when (1) the countable gross nonexempt unearned and earned income received by the eligible group and available to meet the current month’s needs is no more than 185 percent of living costs as identified in the schedule of needs at subrule 75.58(2) for the eligible group (Test 1); (2) the countable net earned and unearned income is less than the schedule of living costs as identified in the schedule of needs at subrule 75.58(2) for the eligible group (Test 2); and (3) the countable net unearned and earned income, after applying allowable disregards, is less than the schedule of basic needs as identified at subrule 75.58(2) for the eligible group (Test 3).
    2. The determination of continuing eligibility is a two-step process. Continuing eligibility shall be granted only when (1) countable gross nonexempt income, as described for initial eligibility, does not exceed 185 percent of the living costs as identified in the schedule of needs at subrule 75.58(2) for the eligible group (Test 1); and (2) countable net unearned and earned income is less than the schedule of basic needs as identified in the schedule of needs at subrule 75.58(2) for the eligible group (Test 3).
    3. Child support assigned to the department in accordance with 441—subrule 41.22(7) shall be considered unearned income for the purpose of determining continuing eligibility, except as specified at paragraphs 75.57(1)“e,”75.57(6)“u,” and 75.57(7)“o.” Expenses for care of children or disabled adults, deductions, and diversions shall be allowed when verification is provided.
      75.57(1)    Unearned income.  Unearned income is any income in cash that is not gained by labor or service. When taxes are withheld from unearned income, the amount considered will be the net income after the withholding of taxes (Federal Insurance Contribution Act, state and federal income taxes). Net unearned income shall be determined by deducting reasonable income-producing costs from the gross unearned income. Money left after this deduction shall be considered gross income available to meet the needs of the eligible group.  a.  Social security income is the amount of the entitlement before withholding of a Medicare premium.  b.  Financial assistance received for education or training. Rescinded IAB 2/11/98, effective 2/1/98.  c.  Rescinded IAB 2/11/98, effective 2/1/98.  d.  When the client sells property on contract, proceeds from the sale shall be considered exempt as income. The portion of any payment that represents principal is considered a resource upon receipt as defined in subrule 75.56(4). The interest portion of the payment is considered a resource the month following the month of receipt.  e.  Support payments in cash shall be considered as unearned income in determining initial and continuing eligibility.  (1)  Any nonexempt cash support payment, for a member of the eligible group, made while the application is pending shall be treated as unearned income.  (2)  Support payments shall be considered as unearned income in the month in which the IV-A agency (income maintenance) is notified of the payment by the IV-D agency (child support recovery unit).The amount of income to consider shall be the actual amount paid or the monthly entitlement, whichever is less.  (3)  Support payments reported by child support recovery during a past month for which eligibility is being determined shall be used to determine eligibility for the month. Support payments anticipated to be received in future months shall be used to determine eligibility for future months. When support payments terminate in the month of decision of an FMAP-related Medicaid application, both support payments already received and support payments anticipated to be received in the month of decision shall be used to determine eligibility for that month.  (4)  When the reported support payment, combined with other income, creates ineligibility under the current coverage group, an automatic redetermination of eligibility shall be conducted in accordance with the provisions of rule 441—76.11(249A). Persons receiving Medicaid under the family medical assistance program in accordance with subrule 75.1(14) may be entitled to continued coverage under the provisions of subrule 75.1(21). Eligibility may be reestablished for any month in which the countable support payment combined with other income meets the eligibility test.  f.  The client shall cooperate in supplying verification of all unearned income and of any change in income, as defined at rule 441—75.50(249A).  (1)  When the information is available, the department shall verify job insurance benefits by using information supplied to the department by Iowa workforce development. When the department uses this information as verification, job insurance benefits shall be considered received the second day after the date that the check was mailed by Iowa workforce development. When the second day falls on a Sunday or federal legal holiday, the time shall be extended to the next mail delivery day.  (2)  When the client notifies the department that the amount of job insurance benefits used is incorrect, the client shall be allowed to verify the discrepancy. The client must report the discrepancy before the eligibility month or within ten days of the date on the Notice of Decision, Form 470-0485, 470-0485(S), 470-0486, or 470-0486(S), applicable to the eligibility month, whichever is later.  75.57(2)    Earned income.  Earned income is defined as income in the form of a salary, wages, tips, bonuses, commission earned as an employee, income from Job Corps, or profit from self-employment. Earned income from commissions, wages, tips, bonuses, Job Corps, or salary means the total gross amount irrespective of the expenses of employment. With respect to self-employment, earned income means the net profit from self-employment, defined as gross income less the allowable costs of producing the income. Income shall be considered earned income when it is produced as a result of the performance of services by an individual.  a.  Each person in the assistance unit whose gross nonexempt earned income, earned as an employee or net profit from self-employment, considered in determining eligibility is entitled to one 20 percent earned income deduction of nonexempt monthly gross earnings. The deduction is intended to include work-related expenses other than child care. These expenses shall include, but are not limited to, all of the following: taxes, transportation, meals, uniforms, and other work-related expenses.  b.  Each person in the assistance unit is entitled to a deduction for care expenses subject to the following limitations.  (1)  Persons in the eligible group and excluded parents shall be allowed care expenses for a child or incapacitated adult in the eligible group.  (2)  Stepparents as described at paragraph 75.57(8)“b” and self-supporting parents on underage parent cases as described at paragraph 75.57(8)“c” shall be allowed incapacitated adult care or child care expenses for the ineligible dependents of the stepparent or self-supporting parent.  (3)  Unless both parents are in the home and one parent is physically and mentally able to provide the care, child care or care for an incapacitated adult shall be considered a work expense in the amount paid for care of each child or incapacitated adult, not to exceed $175 per month, or $200 per month for a child under the age of two, or the going rate in the community, whichever is less.  (4)  If both parents are in the home, adult or child care expenses shall not be allowed when one parent is unemployed and is physically and mentally able to provide the care.  (5)  The deduction is allowable only when the care covers the actual hours of the individual’s employment plus a reasonable period of time for commuting; or the period of time when the individual who would normally care for the child or incapacitated adult is employed at such hours that the individual is required to sleep during the waking hours of the child or incapacitated adult, excluding any hours a child is in school.  (6)  Any special needs of a physically or mentally handicapped child or adult shall be taken into consideration in determining the deduction allowed.  (7)  If the amount claimed is questionable, the expense shall be verified by a receipt or a statement from the provider of care. The expense shall be allowed when paid to any person except a parent or legal guardian of the child, another member of the eligible group, or any person whose needs are met by diversion of income from any person in the eligible group.  c.  Work incentive disregard. After deducting the allowable work-related expenses as defined at paragraphs 75.57(2)“a” and “b” and income diversions as defined at subrule 75.57(4), 58 percent of the total of the remaining monthly nonexempt earned income, earned as an employee or the net profit from self-employment, of each person whose income must be considered is disregarded in determining eligibility for the family medical assistance program (FMAP) and those FMAP-related coverage groups subject to the three-step process for determining initial eligibility as described at rule 441—75.57(249A).  (1)  The work incentive disregard is not time-limited.  (2)  Initial eligibility under the first two steps of the three-step process is determined without the application of the work incentive disregard as described at subparagraphs 75.57(9)“a”(2) and (3).  (3)  A person who is not eligible for Medicaid because the person has refused to cooperate in applying for or accepting benefits from other sources, in accordance with the provisions of rule 441—75.2(249A), 441—75.3(249A), or 441—75.21(249A), is eligible for the work incentive disregard.  d.  Rescinded IAB 6/30/99, effective 9/1/99.  e.  A person is considered self-employed when the person:  (1)  Is not required to report to the office regularly except for specific purposes such as sales training meetings, administrative meetings, or evaluation sessions.  (2)  Establishes the person’s own working hours, territory, and methods of work.  (3)  Files quarterly reports of earnings, withholding payments, and FICA payments to the Internal Revenue Service.  f.  The net profit from self-employment income in a non-home-based operation shall be determined by deducting only the following expenses that are directly related to the production of the income:  (1)  The cost of inventories and supplies purchased that are required for the business, such as items for sale or consumption and raw materials.  (2)  Wages, commissions, and mandated costs relating to the wages for employees of the self-employed.  (3)  The cost of shelter in the form of rent, the interest on mortgage or contract payments; taxes; and utilities.  (4)  The cost of machinery and equipment in the form of rent or the interest on mortgage or contract payments.  (5)  Insurance on the real or personal property involved.  (6)  The cost of any repairs needed.  (7)  The cost of any travel required.  (8)  Any other expense directly related to the production of income, except the purchase of capital equipment and payment on the principal of loans for capital assets and durable goods or any cost of depreciation.  g.  When the client is renting out apartments in the client’s home, the following shall be deducted from the gross rentals received to determine the profit:  (1)  Shelter expense in excess of that set forth on the chart of basic needs components at subrule 75.58(2) for the eligible group.  (2)  That portion of expense for utilities furnished to tenants which exceeds the amount set forth on the chart of basic needs components at subrule 75.58(2).  (3)  Ten percent of gross rentals to cover the cost of upkeep.  h.  In determining profit from furnishing board, room, operating a family-life home, or providing nursing care, the following amounts shall be deducted from the payments received:  (1)  $41 plus an amount equivalent to the monthly maximum food assistance program benefit for a one-member household for a boarder and roomer or an individual in the home to receive nursing care, or $41 for a roomer, or an amount equivalent to the monthly maximum food assistance program benefit for a one-member household for a boarder.  (2)  Ten percent of the total payment to cover the cost of upkeep for individuals receiving a room or nursing care.  i.  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 profit 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 requests to have expenses in excess of the 40 percent considered, profit shall be determined in the same manner as specified at paragraph 75.57(2)“j.”  j.  In determining profit for a self-employed enterprise in the home other than providing room and board, renting apartments or providing child care services, the following expenses shall be deducted from the income received:  (1)  The cost of inventories and supplies purchased that are required for the business, such as items for sale or consumption and raw materials.  (2)  Wages, commissions, and mandated costs relating to the wages for employees.  (3)  The cost of machinery and equipment in the form of rent; or the interest on mortgage or contract payment; and any insurance on such machinery equipment.  (4)  Ten percent of the total gross income to cover the costs of upkeep when the work is performed in the home.  (5)  Any other direct cost involved in the production of the income, except the purchase of capital equipment and payment on the principal of loans for capital equipment and payment on the principal of loans for capital assets and durable goods or any cost of depreciation.  k.  Rescinded IAB 6/30/99, effective 9/1/99.  l.  The applicant or member shall cooperate in supplying verification of all earned income and of any change in income, as defined at rule 441—75.50(249A). A self-employed applicant or member shall keep any records necessary to establish eligibility.  75.57(3)    Shared living arrangements.  When an applicant or member shares living arrangements with another family or person, funds combined to meet mutual obligations for shelter and other basic needs are not income. Funds made available to the applicant or member, exclusively for the applicant’s or member’s needs, are considered income.  75.57(4)    Diversion of income.    a.  Nonexempt earned and unearned income of the parent shall be diverted to meet the unmet needs of the ineligible children of the parent living in the family group who meet the age and school attendance requirements specified in subrule 75.54(1). Income of the parent shall be diverted to meet the unmet needs of the ineligible children of the parent and a companion in the home only when the income and resources of the companion and the children are within family medical assistance program standards. The maximum income that shall be diverted to meet the needs of the ineligible children shall be the difference between the needs of the eligible group if the ineligible children were included and the needs of the eligible group with the ineligible children excluded, except as specified at paragraph 75.57(8)“b.”  b.  Nonexempt earned and unearned income of the parent shall be diverted to permit payment of court-ordered support to children not living with the parent when the payment is actually being made.  75.57(5)    Income of unmarried specified relatives under the age of 19.    a.  Income of the unmarried specified relative under the age of 19 when that specified relative lives with a parent who receives coverage under family medical assistance-related programs or lives with a nonparental relative or in an independent living arrangement.  (1)  The income of the unmarried, underage specified relative who is also an eligible child in the eligible group of the specified relative’s parent shall be treated in the same manner as that of any other child. The income for the unmarried, underage specified relative who is not an eligible child in the eligible group of the specified relative’s parent shall be treated in the same manner as though the specified relative had attained majority.  (2)  The income of the unmarried, underage specified relative living with a nonparental relative or in an independent living arrangement shall be treated in the same manner as though the specified relative had attained majority.  b.  Income of the unmarried specified relative under the age of 19 who lives in the same home as a self-supporting parent. The income of the unmarried specified relative under the age of 19 living in the same home as a self-supporting parent shall be treated in accordance with subparagraphs (1), (2), and (3) below.  (1)  When the unmarried specified relative is under the age of 18 and not a parent of the dependent child, the income of the specified relative shall be exempt.  (2)  When the unmarried specified relative is under the age of 18 and a parent of the dependent child, the income of the specified relative shall be treated in the same manner as though the specified relative had attained majority. The income of the specified relative’s self-supporting parents shall be treated in accordance with paragraph 75.57(8)“c.”  (3)  When the unmarried specified relative is 18 years of age, the specified relative’s income shall be treated in the same manner as though the specified relative had attained majority.  75.57(6)    Exempt as income and resources.  The following shall be exempt as income and resources:  a.  Food reserves from home-produced garden products, orchards, domestic animals, and the like, when used by the household for its own consumption.  b.  The value of the food assistance program benefit.  c.  The value of the United States Department of Agriculture donated foods (surplus commodities).  d.  The value of supplemental food assistance received under the Child Nutrition Act and the special food service program for children under the National School Lunch Act.  e.  Any benefits received under Title III-C, Nutrition Program for the Elderly, of the Older Americans Act.  f.  Benefits paid to eligible households under the Low Income Home Energy Assistance Act of 1981.  g.  Any payment received under Title II of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 and the Federal-Aid Highway Act of 1968.  h.  Any judgment funds that have been or will be distributed per capita or held in trust for members of any Indian tribe. When the payment, in all or part, is converted to another type of resource, that resource is also exempt.  i.  Payments to volunteers participating in the Volunteers in Service to America (VISTA) program, except that this exemption will not be applied when the director of ACTION determines that the value of all VISTA payments, adjusted to reflect the number of hours the volunteers are serving, is equivalent to or greater than the minimum wage then in effect under the Fair Labor Standards Act of 1938, or the minimum wage under the laws of the state where the volunteers are serving, whichever is greater.  j.  Payments for supporting services or reimbursement of out-of-pocket expenses received by volunteers in any of the programs established under Titles II and III of the Domestic Volunteer Services Act.  k.  Tax-exempt portions of payments made pursuant to the Alaskan Native Claims Settlement Act.  l.  Experimental housing allowance program payments made under annual contribution contracts entered into prior to January 1, 1975, under Section 23 of the U.S. Housing Act of 1936 as amended.  m.  The income of a supplemental security income recipient.  n.  Income of an ineligible child.  o.  Income in-kind.  p.  Family support subsidy program payments.  q.  Grants obtained and used under conditions that preclude their use for current living costs.  r.  All earned and unearned educational funds of an undergraduate or graduate student or a person in training. Any extended social security or veterans benefits received by a parent or nonparental relative as defined at subrule 75.55(1), conditional to school attendance, shall be exempt. However, any additional amount received for the person’s dependents who are in the eligible group shall be counted as nonexempt income.  s.  Subsidized guardianship program payments.  t.  Any income restricted by law or regulation which is paid to a representative payee living outside the home, unless the income is actually made available to the applicant or member by the representative payee.  u.  The first $50 received by the eligible group which represents a current monthly support obligation or a voluntary support payment, paid by a legally responsible individual, but in no case shall the total amount exempted exceed $50 per month per eligible group.  v.  Bona fide loans. Evidence of a bona fide loan may include any of the following:  (1)  The loan is obtained from an institution or person engaged in the business of making loans.  (2)  There is a written agreement to repay the money within a specified time.  (3)  If the loan is obtained from a person not normally engaged in the business of making a loan, there is borrower’s acknowledgment of obligation to repay (with or without interest), or the borrower expresses intent to repay the loan when funds become available in the future, or there is a timetable and plan for repayment.  w.  Payments made from the Agent Orange Settlement Fund or any other fund established pursuant to the settlement in the In re Agent Orange product liability litigation, M.D.L. No.381 (E.D.N.Y.).  x.  The income of a person ineligible due to receipt of state-funded foster care, IV-E foster care, or subsidized adoption assistance.  y.  Payments for major disaster and emergency assistance provided under the Disaster Relief Act of 1974 as amended by Public Law 100-707, the Disaster Relief and Emergency Assistance Amendments of 1988.  z.  Payments made to certain United States citizens of Japanese ancestry and resident Japanese aliens under Section 105 of Public Law 100-383, and payments made to certain eligible Aleuts under Section 206 of Public Law 100-383, entitled “Wartime Relocation of Civilians.”  aa.  Payments received from the Radiation Exposure Compensation Act.  ab.  Deposits into an individual development account (IDA) when determining eligibility. The amount of the deposit is exempt as income and shall not be used in the 185 percent eligibility test. Deposits shall be deducted from nonexempt earned and unearned income beginning with the month following the month in which verification that deposits have begun is received. The client shall be allowed a deduction only when the deposit is made from the client’s money. The earned income deductions at paragraphs 75.57(2)“a,” “b,” and “c” shall be applied to nonexempt earnings from employment or net profit from self-employment that remains after deducting the amount deposited into the account. Allowable deductions shall be applied to any nonexempt unearned income that remains after deducting the amount of the deposit. If the client has both nonexempt earned and unearned income, the amount deposited into the IDA account shall first be deducted from the client’s nonexempt unearned income. Deposits shall not be deducted from earned or unearned income that is exempt.  75.57(7)    Exempt as income.  The following are exempt as income.  a.  Reimbursements from a third party.  b.  Reimbursement from the employer for a job-related expense.  c.  The following nonrecurring lump sum payments:  (1)  Income tax refund.  (2)  Retroactive supplemental security income benefits.  (3)  Settlements for the payment of medical expenses.  (4)  Refunds of security deposits on rental property or utilities.  (5)  That part of a lump sum received and expended for funeral and burial expenses.  (6)  That part of a lump sum both received and expended for the repair or replacement of resources.  d.  Payments received by the family for providing foster care when the family is operating a licensed foster home.  e.  A small monetary nonrecurring gift, such as a Christmas, birthday or graduation gift, not to exceed $30 per person per calendar quarter.When a monetary gift from any one source is in excess of $30, the total gift is countable as unearned income. When monetary gifts from several sources are each $30 or less, and the total of all gifts exceeds $30, only the amount in excess of $30 is countable as unearned income.  f.  Federal or state earned income tax credit.  g.  Supplementation from county funds, providing:  (1)  The assistance does not duplicate any of the basic needs as recognized by the chart of basic needs components in accordance with subrule 75.58(2), or   (2)  The assistance, if a duplication of any of the basic needs, is made on an emergency basis, not as ongoing supplementation.  h.  Any payment received as a result of an urban renewal or low-cost housing project from any governmental agency.  i.  A retroactive corrective family investment program (FIP) payment.  j.  The training allowance issued by the division of vocational rehabilitation, department of education.  k.  Payments from the PROMISE JOBS program.  l.  The training allowance issued by the department for the blind.  m.  Payments from passengers in a car pool.  n.  Support refunded by the child support recovery unit for the first month of termination of eligibility and the family does not receive the family investment program.  o.  Rescinded IAB 10/4/00, effective 10/1/00.  p.  Rescinded IAB 10/4/00, effective 10/1/00.  q.  Income of a nonparental relative as defined at subrule 75.55(1) except when the relative is included in the eligible group.  r.  Rescinded IAB 10/4/00, effective 10/1/00.  s.  Compensation in lieu of wages received by a child funded through an employment and training program of the U.S. Department of Labor.  t.  Any amount for training expenses included in a payment funded through an employment and training program of the U.S. Department of Labor.  u.  Earnings of a person aged 19 or younger who is a full-time student as defined at subparagraphs 75.54(1)“b”(1) and (2). The exemption applies through the entire month of the person’s twentieth birthday.Exception: When the twentieth birthday falls on the first day of the month, the exemption stops on the first day of that month.  v.  Income attributed to an unmarried, underage parent in accordance with paragraph 75.57(8)“c” effective the first day of the month following the month in which the unmarried, underage parent turns age 18 or reaches majority through marriage. When the unmarried, underage parent turns 18 on the first day of a month, the income of the self-supporting parents becomes exempt as of the first day of that month.  w.  Incentive payments received from participation in the adolescent pregnancy prevention programs.  x.  Payments received from the comprehensive child development program, funded by the Administration for Children, Youth, and Families, provided the payments are considered complimentary assistance by federal regulation.  y.  Incentive allowance payments received from the work force investment project, provided the payments are considered complimentary assistance by federal regulation.  z.  Interest and dividend income.  aa.  Rescinded IAB 10/4/00, effective 10/1/00.  ab.  Honorarium income. All moneys paid to an eligible household in connection with the welfare reform demonstration longitudinal study or focus groups shall be exempted.  ac.  Income that an individual contributes to a trust as specified at paragraph 75.24(3)“b” shall not be considered for purposes of determining eligibility for the family medical assistance program (FMAP) or FMAP-related Medicaid coverage groups.  ad.  Benefits paid to the eligible household under the family investment program (FIP).  ae.  Moneys received through the pilot self-sufficiency grants program or through the pilot diversion program.  af.  Earnings from new employment of any person whose income is considered when determining eligibility during the first four calendar months of the new employment. The date the new employment or self-employment begins shall be verified before approval of the exemption. This four-month period shall be referred to as the work transition period (WTP).  (1)  The exempt period starts the first day of the month in which the client receives the first pay from the new employment and continues through the next three benefit months, regardless if the job ends during the four-month period.  (2)  To qualify for this disregard, the person shall not have earned more than $1,200 in the 12 calendar months prior to the month in which the new job begins, the income must be reported timely in accordance with rule 441—76.10(249A), and the new job must have started after the date the application is filed. For purposes of this policy, the $1,200 earnings limit applies to the gross amount of income without any allowance for exemptions, disregards, work deductions, diversions, or the costs of doing business used in determining net profit from any income test in rule 441—75.57(249A).  (3)  If another new job or self-employment enterprise starts while a WTP is in progress, the exemption shall also be applied to earnings from the new source that are received during the original 4-month period, provided that the earnings were less than $1,200 in the 12-month period before the month the other new job or self-employment enterprise begins.  (4)  An individual is allowed the 4-month exemption period only once in a 12-month period. An additional 4-month exemption shall not be granted until the month after the previous 12-month period has expired.  (5)  If a person whose income is considered enters the household, the new job must start after the date the person enters the home or after the person is reported in the home, whichever is later, in order for that person to qualify for the exemption.  (6)  When a person living in the home whose income is not considered subsequently becomes an assistance unit member whose income is considered, the new job must start after the date of the change that causes the person’s income to be considered in order for that person to qualify for the exemption.  (7)  A person who begins new employment or self-employment that is intermittent in nature may qualify for the WTP. “Intermittent” includes, but is not limited to, working for a temporary agency that places the person in different job assignments on an as-needed or on-call basis, or self-employment from providing child care for one or more families. However, a person is not considered as starting new employment or self-employment each time intermittent employment restarts or changes such as when the same temporary agency places the person in a new assignment or a child care provider acquires another child care client.  ag.  Payments from property sold under an installment contract as specified in paragraphs 75.56(4)“b” and 75.57(1)“d.”  ah.  All census earnings received by temporary workers from the Bureau of the Census.  ai.  Payments received through participation in the preparation for adult living program pursuant to 441—Chapter 187.  75.57(8)    Treatment of income in excluded parent cases, stepparent cases, and underage parent cases.    a.    Treatment of income in excluded parent cases.  A parent who is living in the home with the eligible children but who is not eligible for Medicaid is eligible for the 20 percent earned income deduction, child care expenses for children in the eligible group, the 58 percent work incentive disregard described at paragraphs 75.57(2)“a,” “b,” and “c,” and diversions described at subrule 75.57(4). All remaining nonexempt income of the parent shall be applied against the needs of the eligible group.  b.    Treatment of income in stepparent cases.  The income of a stepparent who is not included in the eligible group but who is living with the parent in the home of an eligible child shall be given the same consideration and treatment as that of a parent subject to the limitations of subparagraphs (1) through (10) below.  (1)  The stepparent’s monthly gross nonexempt earned income, earned as an employee or monthly net profit from self-employment, shall receive a 20 percent earned income deduction.  (2)  The stepparent’s monthly nonexempt earned income remaining after the 20 percent earned income deduction shall be allowed child care expenses for the stepparent’s ineligible dependents in the home, subject to the restrictions described at subparagraphs 75.57(2)“b”(1) through (5).  (3)  Any amounts actually paid by the stepparent to individuals not living in the home, who are claimed or could be claimed by the stepparent as dependents for federal income tax purposes, shall be deducted from nonexempt monthly earned and unearned income of the stepparent.  (4)  The stepparent shall also be allowed a deduction from nonexempt monthly earned and unearned income for alimony and child support payments made to individuals not living in the home with the stepparent.  (5)  Except as described at subrule 75.57(10), the nonexempt monthly earned and unearned income of the stepparent remaining after application of the deductions at subparagraphs 75.57(8)“b”(1) through (4) above shall be used to meet the needs of the stepparent and the stepparent’s dependents living in the home, when the dependents’ needs are not included in the eligible group and the stepparent claims or could claim the dependents for federal income tax purposes. These needs shall be determined in accordance with the schedule of needs for a family group of the same composition in accordance with subrule 75.58(2).  (6)  The stepparent shall be allowed the 58 percent work incentive disregard from monthly earnings. The disregard shall be applied to earnings that remain after all other deductions at subparagraphs 75.57(8)“b”(1) through (5) have been subtracted from the earnings. However, the work incentive disregard is not allowed when determining initial eligibility as described at subparagraphs 75.57(9)“a”(2) and (3).  (7)  The deductions described in subparagraphs (1) through (6) shall first be subtracted from earned income in the same order as they appear above.When the stepparent has both nonexempt earned and unearned income and earnings are less than the allowable deductions, then any remaining portion of the deductions in subparagraphs (3) through (5) shall be subtracted from unearned income. Any remaining income shall be applied as unearned income to the needs of the eligible group.If the stepparent has earned income remaining after allowable deductions, then any nonexempt unearned income shall be added to the earnings and the resulting total counted as unearned income to the needs of the eligible group.  (8)  A nonexempt, nonrecurring lump sum received by a stepparent shall be considered as income and counted in computing eligibility in the same manner as it would be treated for a parent. Any portion of the nonrecurring lump sum retained by the stepparent in the month following the month of receipt shall be considered a resource to the stepparent if that portion is not exempted according to paragraph 75.56(1)“f.”  (9)  When the income of the stepparent, not in the eligible group, is insufficient to meet the needs of the stepparent and the stepparent’s dependents living in the home who are not eligible for FMAP-related Medicaid, the income of the parent may be diverted to meet the unmet needs of the children of the current marriage except as described at subrule 75.57(10).  (10)  When the needs of the stepparent, living in the home, are not included in the eligible group, the eligible group and any children of the parent living in the home who are not eligible for FMAP-related Medicaid shall be considered as one unit, and the stepparent and the stepparent’s dependents, other than the spouse, shall be considered a separate unit.  (11)  Rescinded IAB 6/30/99, effective 9/1/99.  c.    Treatment of income in underage parent cases.  In the case of a dependent child whose unmarried parent is under the age of 18 and living in the same home as the unmarried, underage parent’s own self-supporting parents, the income of each self-supporting parent shall be considered available to the eligible group after appropriate deductions unless the provisions of rule 441—75.59(249A) apply. The deductions to be applied are the same as are applied to the income of a stepparent pursuant to subparagraphs 75.57(8)“b”(1) through (7). Child care expenses at subparagraph 75.57(8)“b”(2) shall be allowed for the self-supporting parent’s ineligible children. Nonrecurring lump sum income received by the self-supporting parent(s) shall be treated in accordance with subparagraph 75.57(8)“b”(8).When the self-supporting spouse of a self-supporting parent is also living in the home, the income of that spouse shall be attributable to the self-supporting parent in the same manner as the income of a stepparent is determined pursuant to subparagraphs 75.57(8)“b”(1) through (7) unless the provisions of rule 441—75.59(249A) apply. Child care expenses at subparagraph 75.57(8)“b”(2) shall be allowed for the ineligible dependents of the self-supporting spouse who is a stepparent of the minor parent. Nonrecurring lump sum income received by the spouse of the self-supporting parent shall be treated in accordance with subparagraph 75.57(8)“b”(8). The self-supporting parent and any ineligible dependents of that person shall be considered as one unit. The self-supporting spouse and the spouse’s ineligible dependents, other than the self-supporting parent, shall be considered a separate unit.  75.57(9)    Budgeting process.    a.  Initial and ongoing eligibility. Both initial and ongoing eligibility shall be based on a projection of income based on the best estimate of future income.  (1)  Upon application, the department shall use all earned and unearned income received by the eligible group to project future income. Allowable work expenses shall be deducted from earned income, except in determining eligibility under the 185 percent test defined at rule 441—75.57(249A). The determination of initial eligibility is a three-step process as described at rule 441—75.57(249A).  (2)  Test 1. When countable gross nonexempt earned and unearned income exceeds 185 percent of the schedule of living costs (Test 1), as identified at subrule 75.58(2) for the eligible group, eligibility does not exist under any coverage group for which these income tests apply. Countable gross income means nonexempt gross income, as defined at rule 441—75.57(249A), without application of any disregards, deductions, or diversions.  (3)  Test 2. When the countable gross nonexempt earned and unearned income equals or is less than 185 percent of the schedule of living costs for the eligible group, initial eligibility under the schedule of living costs (Test 2) shall then be determined. Initial eligibility under the schedule of living costs is determined without application of the 58 percent work incentive disregard as specified at paragraph 75.57(2)“c.” All other appropriate exemptions, deductions and diversions are applied. Countable income is then compared to the schedule of living costs (Test 2) for the eligible group. When countable net earned and unearned income equals or exceeds the schedule of living costs for the eligible group, eligibility does not exist under any coverage group for which these income tests apply.  (4)  Test 3. After application of Tests 1 and 2 for initial eligibility or of Test 1 for ongoing eligibility, the 58 percent work incentive disregard at paragraph 75.57(2)“c” shall be applied when there is eligibility for this disregard. When countable net earned and unearned income, after application of the work incentive disregard and all other appropriate exemptions, deductions, and diversions, equals or exceeds the schedule of basic needs (Test 3) for the eligible group, eligibility does not exist under any coverage group for which these tests apply. When the countable net income is less than the schedule of basic needs for the eligible group, the eligible group meets FMAP or CMAP income requirements.  (5)  Rescinded IAB 10/4/00, effective 10/1/00.  (6)  When income received weekly or biweekly (once every two weeks) is projected for future months, it shall be projected by adding all income received in the time period being used and dividing the result by the number of instances of income received in that time period. The result shall be multiplied by four if the income is received weekly, or by two if the income is received biweekly, regardless of the number of weekly or biweekly payments to be made in future months.  (7)  Rescinded IAB 7/4/07, effective 8/1/07.  (8)  When a change in circumstances that is required to be timely reported by the client pursuant to paragraphs 75.52(4)“d” and “e” is not reported as required, eligibility shall be redetermined beginning with the month following the month in which the change occurred. When a change in circumstances that is required to be reported by the client at annual review or upon the addition of an individual to the eligible group pursuant to paragraph 75.52(4)“c” is not reported as required, eligibility shall be redetermined beginning with the month following the month in which the change was required to be reported. All other changes shall be acted upon when they are reported or otherwise become known to the department, allowing for a ten-day notice of adverse action, if required.  b.  Recurring lump-sum income. Recurring lump-sum earned and unearned income, except for the income of the self-employed, shall be prorated over the number of months for which the income was received and applied to the eligibility determination for the same number of months.  (1)  Income received by an individual employed under a contract shall be prorated over the period of the contract.  (2)  Income received at periodic intervals or intermittently shall be prorated over the period covered by the income and applied to the eligibility determination for the same number of months. Exception: Periodic or intermittent income from self-employment shall be treated as described at paragraph 75.57(9)“i.”  (3)  When the lump-sum income is earned income, appropriate disregards, deductions and diversions shall be applied to the monthly prorated income. Income is prorated when a recurring lump sum is received at any time.  c.  Nonrecurring lump-sum income. Moneys received as a nonrecurring lump sum, except as specified in subrules 75.56(4) and 75.56(7) and at paragraphs 75.57(8)“b” and “c,” shall be treated in accordance with this rule. Nonrecurring lump-sum income includes an inheritance, an insurance settlement or tort recovery, an insurance death benefit, a gift, lottery winnings, or a retroactive payment of benefits, such as social security, job insurance, or workers’ compensation.  (1)  Nonrecurring lump-sum income shall be considered as income in the month of receipt and counted in computing eligibility, unless the income is exempt.  (2)  When countable income exclusive of any family investment program grant but including countable lump-sum income exceeds the needs of the eligible group under their current coverage group, the countable lump-sum income shall be prorated. The number of full months for which a monthly amount of the lump sum shall be counted as income in the eligibility determination is derived by dividing the total of the lump-sum income and any other countable income received in or projected to be received in the month the lump sum was received by the schedule of living costs, as identified at subrule 75.58(2), for the eligible group. This period is referred to as the period of proration. Any income remaining after this calculation shall be applied as income to the first month following the period of proration and disregarded as income thereafter.  (3)  The period of proration shall begin with the month when the nonrecurring lump sum was received, whether or not the receipt of the lump sum was timely reported. If receipt of the lump sum was reported timely and the calculation was completed timely, no recoupment shall be made. If receipt of the lump sum was not reported timely or the calculation was not completed timely, recoupment shall begin with the month of receipt of the nonrecurring lump sum.  (4)  The period of proration shall be shortened when:
    1. The schedule of living costs as defined at subrule 75.58(2) increases; or
    2. A portion of the lump sum is no longer available to the eligible group due to loss or theft or because the person controlling the lump sum no longer resides with the eligible group and the lump sum is no longer available to the eligible group; or
    3. There is an expenditure of the lump sum made for the following circumstances unless there was insurance available to meet the expense: Payments made on medical services for the former eligible group or their dependents for services listed in 441—Chapters 78, 81, 82, and 85 at the time the expense is reported to the department; the cost of necessary repairs to maintain habitability of the homestead requiring the spending of over $25 per incident; cost of replacement of exempt resources as defined in subrule 75.56(1) due to fire, tornado, or other natural disaster; or funeral and burial expenses. The expenditure of these funds shall be verified.
      (5)  When countable income, including the lump-sum income, is less than the needs of the eligible group in accordance with the provisions of their current coverage group, the lump sum shall be counted as income for the month of receipt.  (6)  For purposes of applying the lump-sum provision, the eligible group is defined as all eligible persons and any other individual whose lump-sum income is counted in determining the period of proration.  (7)  During the period of proration, individuals not in the eligible group when the lump-sum income was received may be eligible as a separate eligible group. Income of this eligible group plus income of the parent or other legally responsible person in the home, excluding the lump-sum income already considered, shall be considered as available in determining eligibility.
      d.  The third digit to the right of the decimal point in any calculation of income, hours of employment and work expenses for care, as defined at paragraph 75.57(2)“b,” shall be dropped.  e.  In any month for which an individual is determined eligible to be added to a currently active family medical assistance (FMAP) or FMAP-related Medicaid case, the individual’s needs, income, and resources shall be included. An individual who is a member of the eligible group and who is determined to be ineligible for Medicaid shall be canceled prospectively effective the first of the following month if the timely notice of adverse action requirements as provided at 441—subrule 76.4(1) can be met.  f.  Rescinded IAB 10/4/00, effective 10/1/00.  g.  Rescinded IAB 2/11/98, effective 2/1/98.  h.  Income from self-employment received on a regular weekly, biweekly, semimonthly or monthly basis shall be budgeted in the same manner as the earnings of an employee. The countable income shall be the net income.  i.  Income from self-employment not received on a regular weekly, biweekly, semimonthly or monthly basis that represents an individual’s annual income shall be averaged over a 12-month period of time, even if the income is received within a short period of time during that 12-month period. Any change in self-employment shall be handled in accordance with subparagraphs (3) through (5) below.  (1)  When a self-employment enterprise which does not produce a regular weekly, biweekly, semimonthly or monthly income has been in existence for less than a year, income shall be averaged over the period of time the enterprise has been in existence and the monthly amount projected for the same period of time. If the enterprise has been in existence for such a short time that there is very little income information, the worker shall establish, with the cooperation of the client, a reasonable estimate which shall be considered accurate and projected for three months, after which the income shall be averaged and projected for the same period of time. Any changes in self-employment shall be considered in accordance with subparagraphs (3) through (5) below.  (2)  These policies apply when the self-employment income is received before the month of decision and the income is expected to continue, in the month of decision, after assistance is approved.  (3)  A change in the cost of producing self-employment income is defined as an established permanent ongoing change in the operating expenses of a self-employment enterprise. Change in self-employment income is defined as a change in the nature of business.  (4)  When a change in operating expenses occurs, the department shall recalculate the expenses on the basis of the change.  (5)  When a change occurs in the nature of the business, the income and expenses shall be computed on the basis of the change.
      75.57(10)    Restriction on diversion of income.  Rescinded IAB 7/11/01, effective 9/1/01.  75.57(11)    Divesting of income.  Assistance shall not be approved when an investigation proves that income was divested and the action was deliberate and for the primary purpose of qualifying for assistance or increasing the amount of assistance paid.
    Related ARC(s): 8500B, 8556B, 9043B441—75.58(249A)  Need standards.    75.58(1)    Definition of eligible group.  The eligible group consists of all eligible persons specified below and living together, except when one or more of these persons have elected to receive supplemental security income under Title XVI of the Social Security Act or are voluntarily excluded in accordance with the provisions of rule 441—75.59(249A). There shall be at least one child, which may be an unborn child, in the eligible group except when the only eligible child is receiving supplemental security income.  a.  The following persons shall be included (except as otherwise provided in these rules) without regard to the person’s employment status, income or resources:  (1)  All dependent children who are siblings of whole or half blood or adoptive.  (2)  Any parent of such children, if the parent is living in the same home as the dependent children.  b.  The following persons may be included:  (1)  The needy specified relative who assumes the role of parent.  (2)  The needy specified relative who acts as caretaker when the parent is in the home but is unable to act as caretaker.  (3)  An incapacitated stepparent, upon request, when the stepparent is the legal spouse of the parent by ceremonial or common-law marriage and the stepparent does not have a child in the eligible group.
    1. A stepparent is considered incapacitated when a clearly identifiable physical or mental defect has a demonstrable effect upon earning capacity or the performance of the homemaking duties required to maintain a home for the stepchild. The incapacity shall be expected to last for a period of at least 30 days from the date of application.
    2. The determination of incapacity shall be supported by medical or psychological evidence. The evidence may be submitted either by letter from the physician or on Form 470-0447, Report on Incapacity.
    3. When an examination is required and other resources are not available to meet the expense of the examination, the physician shall be authorized to make the examination and submit the claim for payment on Form 470-0502, Authorization for Examination and Claim for Payment.
    4. A finding of eligibility for social security benefits or supplemental security income benefits based on disability or blindness is acceptable proof of incapacity for the family medical assistance program (FMAP) and FMAP-related program purposes.
    5. A stepparent who is considered incapacitated and is receiving Medicaid shall be referred to the department of education, division of vocational rehabilitation services, for evaluation and services. Acceptance of these services is optional.
      (4)  The stepparent who is not incapacitated when the stepparent is the legal spouse of the parent by ceremonial or common-law marriage and the stepparent is required in the home to care for the dependent children. These services must be required to the extent that if the stepparent were not available, it would be necessary to allow for care as a deduction from earned income of the parent.
      75.58(2)    Schedule of needs.  The schedule of living costs represents 100 percent of the basic needs. The schedule of living costs is used to determine the needs of individuals when these needs must be determined in accordance with the schedule of needs defined at rule 441—75.50(249A). The 185 percent schedule is included for the determination of eligibility in accordance with rule 441—75.57(249A). The schedule of basic needs is used to determine the basic needs of those persons whose needs are included in the eligible group. The eligible group is considered a separate and distinct group without regard to the presence in the home of other persons, regardless of relationship to or whether they have a liability to support members of the eligible group. The schedule of basic needs is also used to determine the needs of persons not included in the eligible group. The percentage of basic needs paid to one or more persons as compared to the schedule of living costs is shown on the chart below:SCHEDULE OF NEEDSNumberofPersons12345678910Each Additional PersonTest 1185% ofLivingCosts675.251330.151570.651824.102020.202249.602469.752695.452915.603189.40320.05Test 2Scheduleof LivingCosts365719849986109212161335145715761724173Test 3Scheduleof BasicNeeds18336142649554861067073179186587Ratio ofBasicNeeds toLivingCosts50.1850.1850.1850.1850.1850.1850.1850.1850.1850.1850.18CHART OF BASIC NEEDS COMPONENTS(all figures are on a per person basis)NumberofPersons12345678910 orMoreShelter77.1465.8147.1035.2031.7426.2825.6922.5220.9120.58Utilities19.2916.4511.778.807.936.576.425.635.235.14HouseholdSupplies4.275.334.013.753.363.263.103.082.972.92Food34.4944.9840.3139.1136.6537.0434.0033.5332.8732.36Clothing11.1711.498.708.756.826.846.546.396.206.10Pers. Care &Supplies3.293.642.682.382.021.911.821.721.671.64Med. ChestSupplies.991.401.341.131.151.111.081.061.091.08Communications7.236.173.853.252.502.071.821.661.511.49Transportation25.1325.2322.2421.3817.4316.5915.2415.7915.4415.19  a.  The definitions of the basic need components are as follows:  (1)  Shelter: Rental, taxes, upkeep, insurance, amortization.  (2)  Utilities: Fuel, water, lights, water heating, refrigeration, garbage.  (3)  Household supplies and replacements: Essentials associated with housekeeping and meal preparation.  (4)  Food: Including school lunches.  (5)  Clothing: Including layette, laundry, dry cleaning.  (6)  Personal care and supplies: Including regular school supplies.  (7)  Medicine chest items.  (8)  Communications: Telephone, newspapers, magazines.  (9)  Transportation: Including bus fares.  b.  Special situations in determining eligible group:  (1)  The needs of a child or children in a nonparental home shall be considered a separate eligible group when the relative is receiving Medicaid for the relative’s own children.  (2)  When the unmarried specified relative under the age of 19 is living in the same home with a parent or parents who receive Medicaid, the needs of the specified relative, when eligible, shall be included in the same eligible group with the parents. When the specified relative is a parent, the needs of the eligible children for whom the unmarried parent is caretaker shall be included in the same eligible group. When the specified relative is a nonparental relative, the needs of the eligible children for whom the specified relative is caretaker shall be considered a separate eligible group.When the unmarried specified relative under the age of 19 is living in the same home as a parent who receives Medicaid but the specified relative is not an eligible child, need of the specified relative shall be determined in the same manner as though the specified relative had attained majority.When the unmarried specified relative under the age of 19 is living with a nonparental relative or in an independent living arrangement, need shall be determined in the same manner as though the specified relative had attained majority.When the unmarried specified relative is under the age of 18 and living in the same home with a parent who does not receive Medicaid, the needs of the specified relative, when eligible, shall be included in the eligible group with the children when the specified relative is a parent. When the specified relative is a nonparental relative as defined at subrule 75.55(1), only the needs of the eligible children shall be included in the eligible group. When the unmarried specified relative is aged 18, need shall be determined in the same manner as though the specified relative had attained majority.  (3)  When a person who would ordinarily be in the eligible group has elected to receive supplemental security income benefits, the person, income and resources shall not be considered in determining eligibility for the rest of the family.  (4)  When two individuals, married to each other, are living in a common household and the children of each of them are recipients of Medicaid, the eligibility shall be computed on the basis of their comprising one eligible group.  (5)  When a child is ineligible for Medicaid, the income and resources of that child are not used in determining eligibility of the eligible group and the ineligible child is not a part of the household size. However, the income and resources of a parent who is ineligible for Medicaid are used in determining eligibility of the eligible group and the ineligible parent is counted when determining household size.
    441—75.59(249A)  Persons who may be voluntarily excluded from the eligible group when determining eligibility for the family medical assistance program (FMAP) and FMAP-related coverage groups.    75.59(1)    Exclusions from the eligible group.  In determining eligibility under the family medical assistance program (FMAP) or any FMAP-related Medicaid coverage group in this chapter, the following persons may be excluded from the eligible group when determining Medicaid eligibility of other household members.  a.  Siblings (of whole or half blood, or adoptive) of eligible children.  b.  Self-supporting parents of minor unmarried parents.  c.  Stepparents of eligible children.  d.  Children living with a specified relative, as listed at subrule 75.55(1).  75.59(2)    Needs, income, and resource exclusions.  The needs, income, and resources of persons who are voluntarily excluded shall also be excluded. If a self-supporting parent of a minor unmarried parent is voluntarily excluded, then the minor unmarried parent shall not be counted in the household size when determining eligibility for the minor unmarried parent’s child. However, the income and resources of the minor unmarried parent shall be used in determining eligibility for the unmarried minor parent’s child. If a stepparent is voluntarily excluded, the natural or adoptive parent shall not be counted in the household size when determining eligibility for the natural or adoptive parent’s children. However, the income and resources of the natural or adoptive parent shall be used in determining eligibility for the natural or adoptive parent’s children.  75.59(3)    Medicaid entitlement.  Persons whose needs are voluntarily excluded from the eligibility determination shall not be entitled to Medicaid under this or any other coverage group.  75.59(4)    Situations where parent’s needs are excluded.  In situations where the parent’s needs are excluded but the parent’s income and resources are considered in the eligibility determination (e.g., minor unmarried parent living with self-supporting parents), the excluded parent shall be allowed the earned income deduction, child care expenses and the work incentive disregard as provided at paragraphs 75.57(2)“a,” “b,” and “c.”  75.59(5)    Situations where child’s needs, income, and resources are excluded.  In situations where the child’s needs, income, and resources are excluded from the eligibility determination pursuant to subrule 75.59(1), and the child’s income is not sufficient to meet the child’s needs, the parent shall be allowed to divert income to meet the unmet needs of the excluded child. The maximum amount to be diverted shall be the difference between the schedule of basic needs of the eligible group with the child included and the schedule of basic needs with the child excluded, in accordance with the provisions of subrule 75.58(2), minus any countable income of the child.441—75.60(249A)  Pending SSI approval.  When a person who would ordinarily be in the eligible group has applied for supplemental security income benefits, the person’s needs may be included in the eligible group pending approval of supplemental security income.441—75.61    Reserved.441—75.62    Reserved.441—75.63    Reserved.441—75.64    Reserved.441—75.65    Reserved.441—75.66    Reserved.441—75.67    Reserved.441—75.68    Reserved.441—75.69    Reserved.DIVISION IIIFINANCIAL ELIGIBILITY BASED ON MODIFIED ADJUSTED GROSS INCOME (MAGI)441—75.70(249A)  Financial eligibility based on modified adjusted gross income (MAGI).  Notwithstanding any other provision of this chapter, effective January 1, 2014, financial eligibility for medical assistance shall be determined using “modified adjusted gross income” (MAGI) and “household income” pursuant to 42 U.S.C. § 1396a(e)(14), to the extent required by that section as a condition of federal funding under Title XIX of the Social Security Act. For this purpose, financial eligibility for medical assistance includes any applicable purpose for which a determination of income is required, including the imposition of any premiums or cost sharing. Related ARC(s): 1134C, 1212C, 1356C, 3354C, 3550C441—75.71(249A)  Income limits.  Notwithstanding any other provision of this chapter, effective January 1, 2014, the following income limits apply to the following coverage groups, as identified by the legal references provided:Coverage GroupLegal ReferenceHousehold Size(persons)Income Limit(per month)Family Medical Assistance Program and Child Medical Assistance Program441—subrule 75.1(14) and 441—subrule 75.1(15); 42 CFR Part 435.110; Title XIX of the Social Security Act, Section 19311$4472$7163$8724$1,0335$1,1776$1,3307$1,4818$1,6339$1,78410$1,950over 10$1,950 plus $178 for each additional personMothers and Children, for pregnant women and for infants under one year of age441—subrule 75.1(28); 42 CFR Part 435.116; Title XIX of the Social Security Act, Section 1902375% of the federal poverty level for the householdMothers and Children, for children aged 1 through 18 years441—subrule 75.1(28); 42 CFR Part 435.116; Title XIX of the Social Security Act, Section 1902167% of the federal poverty level for the householdMedicaid for Independent Young Adults441—subrule 75.1(42); Title XIX of the Social Security Act, Section 1902(a)(10)(A)(ii)(VII)254% of the federal poverty level for the householdRelated ARC(s): 1134C, 1212C, 1356CThese rules are intended to implement Iowa Code section 249A.4.
    Related ARC(s): 7546B, 7741B, 7834B, 7833B, 7929B, 7931B, 7932B, 7935B, 8095B, 8096B, 8260B, 8261B, 8439B, 8443B, 8444B, 8503B, 8500B, 8556B, 8642B, 8713B, 8786B, 8785B, 8898B, 8897B, 9043B, 9044B, 9404B, 9439B, 9582B, 9581B, 9647B, 9696B, 9881B, 9956B, 9957B, 0149C, 0192C, 0579C, 0822C, 0821C, 0820C, 0990C, 1134C, 1212C, 1266C, 1355C, 1356C, 1447C, 1484C, 1483C, 1482C, 2027C, 2029C, 2361C, 2557C, 2605C, 3094C, 3182C, 3183C, 3353C, 3354C, 3493C, 3549C, 3550C, 3869C, 3870C, 3873C, 4208C, 4572C, 4574C