Iowa Administrative Code

under the Iowa wellness plan services will be provided in accordance with 441—Chapter 79 or as provided in a contract between the department or the member’s MCO and the provider. [ARC 0313D, IAB 5/27/26, effective 7/1/26]

74.14(1) If the methodology for calculating the federal medical assistance percentage for eligible individuals, as provided in 42 U.S.C. §1396d(y) as amended to July 1, 2026, is modified through federal law or regulation, in a manner that reduces the percentage of federal assista…

eligibility will be determined according to the requirements of 441—Chapter 75. 74.2(1) Persons covered. Subject to the additional requirements of this chapter and of 441—Chapter 75, medical assistance under IHAWP will be available to persons 19 through 64 years of age who: a. Ar…

441—Chapter 76 apply to applications for IHAWP. [ARC 0313D, IAB 5/27/26, effective 7/1/26]

74.4(1) Countable income. Individuals are financially eligible for IHAWP if their countable income is no more than 133 percent of the FPL as of the date of a decision on initial or ongoing eligibility. 74.4(2) Household size. For financial eligibility purposes, household size wil…

74.5(1) Effective dates of eligibility. IHAWP eligibility will be effective on the first day of the month of application or the first day of the month all eligibility requirements are met, whichever is later. The enrollment period will continue for 12 consecutive months unless th…

74.6(1) Reporting requirements. In addition to the reporting requirements in 441—Chapter 76, as a condition of ongoing enrollment, a member shall report any of the following changes no later than ten calendar days after the change takes place: a. The member enters a nonmedical in…

enrollment period. The reenrollment process will follow the requirements in 441—Chapter 76. [ARC 0313D, IAB 5/27/26, effective 7/1/26]

occurs: 1. The enrollment period ends and coverage for the next enrollment period has not been renewed. 2. The member becomes eligible for medical assistance in a mandatory coverage group under 441—Chapter 75. 3. The member is found to have been ineligible for any reason. 4. The …

incorrectly expended on behalf of the member in accordance with 441—Chapter 75. 74.9(1) The department will recover Medicaid funds expended on behalf of a member from the member’s estate in accordance with 441—Chapter 75. 74.9(2) Funds received from third parties, including Medic…

assistance. 75.10(1) Definitions. The following definitions apply for the purposes of this subrule: a. Institution. “Institution” means an “institution” or a “medical institution” as those terms are defined in 42 CFR §435.1010. For purposes of state placement, “institution” also …

75.11(1) Definitions. For purposes of this rule, the following definitions apply. “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 car…

care or services received while the person is an inmate of a public institution. For the purpose of this rule, “inmate of a public institution” and “public institution” mean the same as defined in 42 CFR Section 435.1010. 75.12(1) Suspension. Medical assistance will be suspended …

75.14(1) As a condition of eligibility, adult Medicaid applicants and members shall cooperate in obtaining medical support for themselves and for any other person in the household for whom Medicaid is requested or received and for whom the applicant or member can legally assign r…

for care through the Department of Veterans Affairs, specialized child health services, services received through Title XVIII of the Act (Medicare), and other resources for meeting the cost of medical care that may be available to the member. These resources must be used when rea…

75.18(1) A pregnant woman who was eligible and enrolled in Medicaid under the provisions of this chapter prior to the end of her pregnancy shall remain continuously eligible throughout the pregnancy and the 12-month postpartum period as provided in subrule 75.3(4), regardless of …

eligible for ongoing Medicaid will retain that eligibility for up to 12 months regardless of changes in family circumstances, except as described in this rule. 75.19(1) Exceptions to coverage. This rule does not apply to the following: a. Children whose eligibility was determined…

groups below receive Medicaid if they meet the eligibility requirements of a related coverage group described in rules 441—75.3(249A) through 441—75.8(249A) and the general conditions of eligibility described within this chapter. 75.2(1) Family-related Medicaid. Medicaid is avail…

following an appeal on a denied application for any of the coverage groups set forth in 441—75.3(249A) through 441—75.8(249A) is favorable to the claimant, reimbursement will be made to the claimant for any medical bills paid by the claimant during the period between the date of …

the department will pay for the cost of premiums, coinsurance, copayments, and deductibles for Medicaid- eligible individuals when the department determines that those costs will be less than the cost of paying for the individual’s care through Medicaid, including managed care ca…

rule, “AIDS” and “HIV” mean the same as defined in Iowa Code section 141A.1. 75.22(1) Conditions of eligibility. The department will pay for the cost of continuing health insurance coverage to persons with AIDS or an HIV-related illness when the following criteria are met: a. The…

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 ha…

an individual’s eligibility for, or the amount of, medical assistance benefits, trusts (except for trusts specified in subrule 75.24(3)) established after August 10, 1993, will be treated in accordance with subrule 75.24(2). 75.24(1) Establishment of trust. a. For the purposes of…

75.25(1) A Medicaid qualifying trust is a trust or similar legal device established on or before August 10, 1993, other than by will by a person or that person’s spouse under which the person may be the beneficiary of payments from the trust and the distribution of these payments…

75.26(1) Conservatorships established prior to February 9, 1994. The department will determine whether assets from a conservatorship established prior to February 9, 1994, except one established solely for the payment of medical expenses, are available by examining the language o…

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 c…

75.28(1) Definitions. For the purposes of this rule, the following definitions apply: “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 Pa…

applicant’s or member’s case is selected by the department or the department of inspections, appeals, and licensing for verification of eligibility unless the investigation revolves solely around the circumstances of a person whose income and resources do not affect Medicaid elig…

caretakers and to pregnant women who meet the eligibility requirements of a coverage group described within this rule and the general conditions of eligibility described in this chapter. 75.3(1) Family medical assistance program (FMAP). Medicaid will be available to low-income ch…

DIVISION II ELIGIBILITY FACTORS SPECIFIC TO FAMILY-RELATED COVERAGE GROUPS

treatment (BCCT). 75.4(1) Medicaid is available to persons who meet the eligibility requirements described within this rule and the general conditions of eligibility described in this chapter. a. Medicaid will be available to persons who: (1) Are under the age of 65: (2) Have bee…

65 and to persons admitted to the United States as refugees who meet the eligibility requirements of a coverage group described within this rule. 75.5(1) Iowa health and wellness plan (IHAWP). This coverage group is available to persons who are aged 19 or older and under the age …

be eligible for FMAP or the coverage groups specified in subrules 75.3(6), 75.3(7), and 75.3(14). 75.50(1) Age and school attendance. Medicaid will be available to a child under the age of 18 without regard to school attendance. a. The effect of age on the child’s eligibility wil…

75.51(1) FMAP and other requirements. To be eligible for FMAP or the coverage groups specified in subrules 75.3(6), 75.3(7), and 75.3(14), a parent or other caretaker must: a. Meet the definition of “parent” or “caretaker” in rule 441—75.1(249A); b. Live with an eligible child as…

reached the age limit, the birth date impacts eligibility for the birth month. 75.52(1) A person is eligible for the entire month in which the person’s birth date occurs, unless the birthday falls on the first day of the month. Ineligibility based on age will be effective the fir…

75.53(1) A person who is absent from the home will not be included in the household, except when temporarily absent as described in subrule 75.53(2). a. A parent who is permitted to live at home while serving a court-imposed sentence by performing unpaid public work or unpaid com…

Medicaid household has applied for SSI benefits, the person’s needs will be included in the family-related Medicaid household pending approval of SSI. [ARC 9763C, IAB 11/26/25, effective 1/1/26]

related Medicaid coverage groups. [ARC 9763C, IAB 11/26/25, effective 1/1/26]

family-related coverage groups will be determined using MAGI methodologies pursuant to Division III of this chapter. [ARC 9763C, IAB 11/26/25, effective 1/1/26]

DIVISION III FINANCIAL ELIGIBILITY BASED ON MODIFIED ADJUSTED GROSS INCOME (MAGI)

a. Persons receiving SSI or state supplementary assistance or eligible for, but not receiving, SSI. b. Aged, blind or disabled persons ineligible for SSI or state supplementary assistance due to income or other requirements. c. Certain persons essential to the welfare of an aged,…

determined to be presumptively eligible for Medicaid pursuant to this subrule. Presumptive eligibility will be determined by a qualified entity (QE) and will be based solely on the applicant’s attested circumstances as provided to the QE and entered by the QE directly online into…

chapter, financial eligibility for Medicaid is determined using MAGI and household income pursuant to 42 U.S.C. §1396a(e)(14) to the extent required by that section as a condition of federal funding under Title XIX of the Act. For this purpose, financial eligibility for Medicaid …

determined under MAGI methodology for the following coverage groups: 1. FMAP as described in subrule 75.3(1). 2. MAC program as described in subrule 75.3(2). 3. Hawki as described in 441—Chapter 86. 4. IHAWP as described in 441—Chapter 74. 5. RMA as described in subrule 75.5(3). …

each applicant’s or member’s household is determined based on federal tax policy and with regard to the applicant’s or member’s federal tax status as described below. 75.72(1) Applicant or member is a tax-filer. An applicant or member who expects to file a federal tax return for …

of the applicant or member included in the household as defined in rule 441—75.72(249A) will be considered when determining initial and ongoing Medicaid eligibility for coverage groups that are subject to MAGI methodology as specified in rule 441—75.71(249A). For eligibility to e…

2. The hawki program limit for a household of the same size as specified in 441—subrule 86.2(2) when the child is aged 0 through 18. b. Presumptive eligibility for parents and other caretakers. Presumptive eligibility will be available to a parent or other caretaker who meets the…

DIVISION IV ELIGIBILITY FACTORS SPECIFIC TO NON-MAGI-RELATED COVERAGE GROUPS, PERSONS IN MEDICAL INSTITUTIONS AND PERSONS RECEIVING LONG-TERM CARE SERVICES