Iowa Administrative Code

hearings. An intentional program violation is determined through a SNAP administrative disqualification hearing, a court conviction, or when an individual signs and returns a form prescribed by the department, which may result in a period of ineligibility for the program, a claim…

DIAL rules found at 481—Chapter 10 govern department appeals. Notwithstanding the foregoing and the rules contained in this chapter, to the extent that federal or state law (including regulations and rules) related to a specific program is more specific than or contradicts these …

DIVISION II APPEALS BASED ON THE COMPETITIVE PROCUREMENT BID PROCESS

7.3(1) Requirements. A person will be granted a contested case hearing if the party-in-interest fulfills all the following requirements: a. The party-in-interest is entitled to a contested case hearing; b. The party-in-interest has an ongoing, specific and personal interest in th…

7.4(1) Exhaustion of remedies. An appellant will only be granted a contested case hearing if the appellant has exhausted all other appeal remedies available to the party-in-interest. An appellant should refer to program-specific provisions for the appropriate procedures applicabl…

department’s competitive procurement bid process. A bidder is an entity that submits a proposal in response to a solicitation issued through the department’s competitive procurement process. [ARC 8897C, IAB 2/19/25, effective 3/26/25]

disqualification or a notice of award, and has first exhausted the reconsideration process, is considered an aggrieved party and may file a written appeal with the department. 7.42(1) An aggrieved party in a competitive procurement must seek reconsideration of a disqualification …

conducted in accordance with the provisions of Division II. Division I of this chapter does not apply to competitive procurement bid appeals unless otherwise noted. 7.43(1) Hearing time frame. The presiding officer shall hold a hearing on the bidder appeal within 60 days of the d…

7.44(1) Discovery. The parties shall serve any discovery requests upon other parties at least 30 days prior to the date set for the hearing. The parties must serve responses to discovery at least 15 days prior to the date set for the hearing. 7.44(2) Witnesses and exhibits. The p…

7.45(1) When a stay may be requested. a. Any party appealing the issuance of a notice of disqualification or notice of award may petition for stay of the decision pending its review. The petition for stay shall be filed with the notice of appeal, shall state the reasons justifyin…

decision shall follow the provisions outlined in rule 441—7.11(17A). [ARC 8897C, IAB 2/19/25, effective 3/26/25]

7.47(1) Consolidation—severance. The provisions regarding consolidation and severance in rule 481—10.10(10A,17A) apply. 7.47(2) Rights of an appellant during a hearing. All rights afforded an appellant in rule 441—7.8(17A) shall apply. [ARC 8897C, IAB 2/19/25, effective 3/26/25]…

7.48(1) The appeal record shall consist of all items specified in Iowa Code section 17A.16. 7.48(2) The party that requests a transcription of the proceedings shall bear the cost. [ARC 8897C, IAB 2/19/25, effective 3/26/25]

[ARC 8897C, IAB 2/19/25, effective 3/26/25]

7.5(1) Ways to request a hearing. An appellant may request a contested case hearing: a. Via the department’s website, b. By telephone, except as specified in subrule 7.5(4), c. By mail, d. In person, except as specified in subrule 7.5(4), or e. Through other commonly available el…

subrule 7.9(1) and Iowa Code section 17A.17 apply. [ARC 8897C, IAB 2/19/25, effective 3/26/25]

7.12(3) and Iowa Code section 17A.19 apply. [ARC 8897C, IAB 2/19/25, effective 3/26/25] These rules are intended to implement Iowa Code chapter 17A. [Filed December 27, 1971; amended December 2, 1974] [Filed 4/30/76, Notice 3/22/76—published 5/17/76, effective 7/1/76] [Filed 9/29…

7.6(1) Acknowledgment of appeal. When the appeals section receives a request for appeal, it will send acknowledgment of the receipt of the appeal to the parties to the appeal. For an appeal regarding child abuse, all subjects other than the person alleged responsible (party-in-in…

7.7(1) Medical assistance. In cases involving the determination of medical assistance, the contested case hearing shall be held within a time frame such that the final administrative action is timely pursuant to 42 CFR 431.244(f) as amended to December 8, 2021. 7.7(2) Community s…

7.8(1) Method. Contested case hearings may be conducted via telephone or videoconference. Upon request of a party to the appeal or order of the presiding officer, the contested case hearing shall be conducted in person. 7.8(2) Evidence. a. The parties to a contested case hearing …

7.9(1) Ex parte communication. Ex parte communications between the presiding officer and person or party in connection with any issue of fact or law in the contested case proceeding is prohibited except as permitted by Iowa Code section 17A.17. All of the provisions of Iowa Code …

“Appeal” means a review by an MCO or PAHP of an adverse benefit determination as specified in 42 CFR 438.400(b). “Capitation payment” means a monthly payment to the MCP on behalf of each enrollee for the provision of health or dental services under the contract. Payment is made r…

approval by the department, that protect an enrollee from involuntary discharge that may lead to placement in an inappropriate or more restrictive setting. The MCO shall facilitate a seamless transition whenever an enrollee transitions between facilities or residences. [ARC 0312D…

73.11(1) The department will retain full authority to determine whether the Medicaid LOC or needs- based assessment has been completed in a timely manner by the appointed vendor. The MCO will be notified once an enrolled member’s LOC determination has been completed. The LOC and …

procedures for an enrollee, or an enrollee’s authorized representative, to appeal an MCP action. The policies must address contractual requirements and federal funding requirements, including 42 CFR 438, Subpart F. 73.12(1) MCP appealable actions. MCP actions that may be appealed…

by the MCP through the MCP’s first-level appeal process, the enrollee may file an appeal with the department. This process is referred to as a state fair hearing, an action in accordance with the appeal process available to all persons receiving Medicaid-funded services as set fo…

benefits during any appeal in accordance with federal funding requirements, including 42 CFR 438.420. 73.14(1) If the benefits are continued or reinstated while the appeal is pending, the benefits must be continued until one of the following occurs: a. The enrollee withdraws the …

dissatisfaction about any matter other than an adverse benefit determination. Grievances may include but are not limited to quality of care or services provided, aspects of interpersonal relations such as rudeness of a provider or employee, or failure to respect the enrollee’s ri…

to the department. The log shall include the status and resolution of all appeals and grievances pursuant to 42 CFR 438.416. [ARC 0312D, IAB 5/27/26, effective 7/1/26]

actions. The MCP’s written procedures for the review of MCP’s decisions and actions shall be provided to each new enrollee in a member handbook, to participating providers in a provider manual, and to nonparticipating providers upon request. [ARC 0312D, IAB 5/27/26, effective 7/1…

73.18(1) Records system. The MCPs shall document and maintain clinical and fiscal records in accordance with federal and state requirements, including 441—Chapter 79 and 42 CFR 456, throughout the course of the contract. The records system shall: a. Identify transactions with or …

Human Services (HHS) may evaluate through inspections or other means the quality, appropriateness, and timeliness of services performed by the MCP. The department or HHS may audit and inspect any records of an MCP, or the subcontractor of the MCP, that pertain to services perform…

73.2(1) The department may enter into a contract with an MCP licensed under the provisions of insurance division rules set forth in 191—Chapter 40 for the scope of services as described in rule 441—73.6(249A). 73.2(2) The department will determine that the MCP meets the following…

and regulations regarding marketing by the MCP and contract terms. The department will approve all marketing materials, which must comply with federal funding requirements, including 42 CFR 438.10 and 42 CFR 438.104. [ARC 0312D, IAB 5/27/26, effective 7/1/26]

73.21(1) Use of services. The MCP shall provide written information to all enrollees on the use of the services the MCP is responsible to arrange, monitor, and reimburse. Information must include the array of services covered; how to access covered services; the providers partici…

73.22(1) Capitation rate. In consideration for all services rendered by an MCP under a contract with the department, the MCP will receive a payment each month for each enrolled member. The monthly reimbursement may be reduced by amounts withheld for pay-for-performance components…

73.23(1) The MCOs shall pay or deny: a. Ninety percent of all clean claims within 30 calendar days of receipt, b. Ninety-nine point five percent of all clean claims within 90 calendar days of receipt, and c. Ninety-five percent of all claims within 45 calendar days of receipt. 73…

performance improvement system that meets the requirements of any or all applicable state and federal laws. [ARC 0312D, IAB 5/27/26, effective 7/1/26]

policies, procedures, and a mandatory compliance plan to ensure compliance with the contract requirements for certification, program integrity and prohibited affiliations. The MCP shall cooperate and collaborate with the department on all program integrity activities. The MCP sha…

73.3(1) Enrollment area. The coverage area for enrollment shall be statewide. 73.3(2) Members subject to enrollment. All hawki program, IHAWP, and dental wellness plan members shall be subject to mandatory enrollment in an MCP. All Medicaid members, with the exception of the foll…

73.4(1) Enrollee-requested disenrollment. An enrollee may request disenrollment with an MCP as follows: a. During the first 90 days following the date of the enrollee’s initial enrollment with the MCP, the enrollee may request disenrollment, for any reason, in writing or by a tel…

73.5(1) Required services—MCOs. An MCO shall provide: a. For all enrolled members, services as set forth in 441—Chapters 78, 81, 82, 83, 84, 85, and 87, with the exception of the following: (1) Area education agency services. (2) Dental services not provided in an outpatient hosp…

73.6(1) The MCP shall provide, at a minimum, all benefits and services deemed medically necessary that are covered under the contract with the department. In accordance with federal funding requirements, including 42 CFR 438.210(a)(3), the MCP shall furnish covered services in an…

73.7(1) Emergency services shall be available 24 hours a day, seven days a week. 73.7(2) In accordance with federal funding requirements, including 42 CFR 438.114, the MCP shall: a. Cover emergency services without the need for prior authorization and shall not limit reimbursemen…

73.8(1) The MCP shall ensure enrollees have access to services as specified in the contract. The MCP shall provide available, accessible, and adequate numbers of institutional facilities, service locations, and service sites and professional, allied, and paramedical personnel for…

73.9(1) The MCO shall develop and implement a critical incident reporting and management system for participating providers in accordance with the department requirements for reporting incidents for Section 1915(c) HCBS waivers; for the Section 1915(i) habilitation program; and a…

definitions in 441—Chapter 75. “Caretaker” means the same as defined in rule 441—75.1(249A). “Countable income” means “modified adjusted gross income” (MAGI) or “household income,” as applicable, determined pursuant to 42 U.S.C. §1396a(e)(14) as amended to July 1, 2026. “Enrollme…

74.10(1) Decisions and actions by the department regarding eligibility or services provided under this chapter may be appealed to the extent permitted by 441—Chapter 2506. 74.10(2) Members will not be entitled to an appeal hearing if the sole basis for denying or limiting service…

74.11(1) Copayment. Payment for nonemergency use of a hospital emergency department shall be subject to an $8 copayment by the member, which will be subtracted from the IHAWP payment otherwise due to the provider. 74.11(2) Monthly contributions. Members enrolled in the IHAWP with…

be determined by the member’s health status. 74.12(1) Iowa wellness plan services. Members shall be enrolled in IHAWP unless the member is determined by the department to be a medically exempt individual. a. Covered Iowa wellness plan services are essential health benefits; all o…