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 PROGRAMS44175.1(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 b. Rescinded IAB 7/30/08, effective 10/1/08.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in 441—Chapter 60, but who do not receive RCA because they did not make application for the assistance. 75.1(2) Rescinded IAB 10/8/97, effective 12/1/97. 75.1(3) Persons who are ineligible for Supplemental Security Income (SSI) because of requirements that do not apply under Title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: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
- Outpatient hospital services.
- Rural health clinic services (if contained in the state plan).
- Clinic services furnished by or under the direction of a physician, without regard to whether the clinic itself is administered by a physician.
- 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).
- 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).
- Participates in a state perinatal program.
- 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.
- There was a serious illness or death of someone in the family.
- There was a family emergency or household disaster, such as a fire, flood, or tornado.
- The family offers a good cause beyond the family’s control.
- 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.
- Remain unpaid as of the first day of the certification period.
- Are not Medicaid-payable in a previous certification period or the retroactive certification period.
- 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.
- Medicare and other health insurance premiums, deductibles, or coinsurance charges.
- 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 by multiplying the previous year’s average per day rate by the inflation factor increase during the preceding calendar year ending December 31 of the Consumer Price Index for All Urban Consumers as published by the Bureau of Labor Statistics.
- Medical expenses for necessary medical and remedial services that are recognized under state law but not covered by Medicaid, chronologically by date of submission.
- Medical expenses for acupuncture, chronologically by date of submission.
- Medical expenses for necessary medical and remedial services that are covered by Medicaid, chronologically by date of submission.
- Form 470-2465, Disability Report for Adults, if the applicant is aged 18 or over; or
- Form 470-3912, Disability Report for Children, if the applicant is under the age of 18.
- 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.
- If the fourteenth day falls on a weekend or a state holiday, payment is due the first working day following the holiday or weekend.
- When any premium payment due in the month it is to cover is not received by the due date, Medicaid eligibility shall be canceled.
- To the month in which the payment is received if the premium for the current calendar month is unpaid.
- To the following month when the payment is received after a billing statement has been issued for the following month.
- 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.
- 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.
- 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.
"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:- Is eligible for payment under the Medicaid program; and
- Either:
- 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.
- Contact the department to obtain a state identification number for the person who has been determined presumptively eligible.
- 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.
- 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.
- 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.
- 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.
- 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.
- Denied presumptive eligibility by a qualified provider.
- 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.
- The person’s own children;
- The person’s spouse; and
- Any children of the person’s spouse who are under the age of 18 and unmarried.
- The child’s parents.
- The child’s siblings under the age of 19.
- The child’s spouse.
- The child’s children.
- The children of the child’s spouse.
- The institutionalized spouse has assigned to the state any rights to support from the community spouse, or
- 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.
- 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;
- 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
- The entrance fee does not confer an ownership interest in the community.
- Has an IQ of 49 or less or has a mental age of seven or less;
- Has been judged legally incompetent; or
- 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.
- 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.
- 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.
"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:
- Placing the patient’s health in serious jeopardy.
- Serious impairment to bodily functions.
- Serious dysfunction of any bodily organ or part.
"Federal means-tested program" means all federal programs that are means-tested with the exception of:
- 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.
- Short-term, non-cash, in-kind emergency disaster relief.
- Assistance or benefits under the National School Lunch Act.
- Assistance or benefits under the Child Nutrition Act of 1966.
- 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.
- 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).
- 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:
- Deliver in-kind services at the community level, including through public or private nonprofit agencies;
- 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
- Are necessary for the protection of life or safety.
- 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.
- Means-tested programs under the Elementary and Secondary Education Act of 1965.
- Benefits under the Head Start Act.
- Benefits funded through an employment and training program of the U.S. Department of Labor.
"Qualified alien" means an alien:
- Who is lawfully admitted for permanent residence in the United States under the Immigration and Nationality Act (INA);
- Who is granted asylum in the United States under Section 208 of the INA;
- Who is a refugee admitted to the United States under Section 207 of the INA;
- Who is paroled into the United States under Section 212(d)(5) of the INA for a period of at least one year;
- 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;
- 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;
- Who is an Amerasian admitted to the United States as described in 8 U.S.C. Section 1612(b)(2)(A)(i)(V);
- Who is a Cuban/Haitian entrant to the United States as described in 8 U.S.C. Section 1641(b)(7);
- Who is a battered alien as described in 8 U.S.C. Section 1641(c);
- 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;
- 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
- 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):- Application for Food Assistance, Form 470-0306 or 470-0307 (Spanish);
- Health and Financial Support Application, Form 470-0462 or 470-0462(S); or
- Review/Recertification Eligibility Document, Form 470-2881, 470-2881(S), 470-2881(M), or 470-2881(MS).
- Requires proof of United States citizenship before issuance of the license or document; or
- 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.
- A certificate of birth in the United States.
- Form FS-545 or Form DS-1350 (Certification of Birth Abroad) issued by the U.S. Citizenship and Immigration Services.
- Form I-97 (United States Citizen Identification Card) issued by the U.S. Citizenship and Immigration Services.
- Form FS-240 (Report of Birth Abroad of a Citizen of the United States) issued by the U.S. Citizenship and Immigration Services.
- 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).
- The applicant has applied to SSA for reconsideration or reopening of its disability decision and SSA refused to consider the new allegations, or
- The applicant no longer meets the nondisability requirements for SSI but may meet the department’s nondisability requirements for Medicaid eligibility.
"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 rule 441—16.3(17A) 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): 3493C, 4973C44175.22(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 16.3(2) 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 rule 441—16.3(17A) 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.Related ARC(s): 4973C44175.23(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:- The first day of the first month during which the assets were transferred; or
- 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.
- The first day of the first month during which the assets were transferred; or
- 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.
- The home if occupied by a dependent relative or if a licensed physician verifies that the person is expected to return home.
- Household goods.
- A vehicle required by the client for transportation.
- Funds for burial of $4,000 or less.
"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:
- The individual or 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.
- 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:
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:- Giving away or selling an interest in an asset;
- Placing an interest in an asset in a trust that is not available to the grantor (see 75.24(2)“b”(2));
- Removing or eliminating an interest in a jointly owned asset in favor of other owners;
- 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”);
- 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
- Transferring or disclaiming the right to income not yet received.
- An account or trust described in Subsection (a), (c), or (p) of Section 408 of the United States Internal Revenue Code of 1986;
- A simplified employee pension (within the meaning of Section 408(k) of the United States Internal Revenue Code of 1986); or
- A Roth IRA described in Section 408A of the United States Internal Revenue Code of 1986.
- Is irrevocable and nonassignable;
- 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
- Provides for payments in equal amounts during the term of the annuity, with no deferral and no balloon payments made.
"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:
- A Medicaid applicant;
- A Medicaid member;
- A person who is conditionally eligible for Medicaid; and
- 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 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, 4208C, 6022C44175.26(249A) References to the family investment program. Rescinded IAB 10/8/97, effective 12/1/97.44175.27(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.4.44175.28(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:
- Misfiling or loss of forms or documents.
- Errors in typing or copying.
- Computer input errors.
- Mathematical errors.
- Failure to determine eligibility correctly or to certify assistance in the correct amount when all essential information was available to the department.
- 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:- Is under the age of 55; and
- Is a resident of a nursing facility, an intermediate care facility for persons with an intellectual disability, or a mental health institute; and
- Cannot reasonably be expected to be discharged and return home.
- 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.
- 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.
"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:
- Hospitals.
- Extended care facilities (skilled nursing).
- Intermediate care facilities.
- Mental health institutions.
- 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.
44175.51(249A) Reinstatement of eligibility. Rescinded IAB 2/10/10, effective 3/1/10.44175.52(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—16.3(17A) 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—16.3(17A).Related ARC(s): 8260B, 8500B, 4973C44175.53(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): 0579C44175.54(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 11/1/08.44175.55(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): 8785B44175.56(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.44175.57(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.- 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).
- 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).
- 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.
- The schedule of living costs as defined at subrule 75.58(2) increases; or
- 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
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.