Iowa Administrative Code

85.7(1) Reimbursement formula. Acute care in psychiatric hospitals will be reimbursed on a per diem rate based on Medicare principles. a. The reimbursement principles follow and comply with the retrospective Principles of Medicare reimbursement found in Title 18 of the Social Sec…

85.8(1) Facility. Acute care in a psychiatric hospital is covered for persons aged 21 through 64 only at the state mental health institutes at Cherokee and Independence. 85.8(2) Basis of eligibility. To be eligible for payment for the cost of care provided by one of the covered f…

Psychiatric medical institutions for children will be issued a license by the department of inspections, appeals, and licensing under Iowa Code chapter 135H and will hold either a license from the department under Iowa Code section 237.3(2)“a”(3), or, for facilities that provide …

“Administrative error” means an action of the department that results in incorrect payment of benefits, including premiums paid to a health or dental plan, due to one or more of the following circumstances: 1. Misfiled or lost form or document. 2. Error in typing or copying. 3. C…

the department. “Timely” shall mean no later than ten working days after the change occurred. The ten working-day period begins the first working day following the date of the change. The parent, guardian, or other adult responsible for the child shall report the change unless th…

decision regarding the applicant’s eligibility for the hawki program. The enrollee will be notified in writing of any decision that adversely affects the enrollee’s eligibility or the amount of benefits. The notice will be timely and adequate as provided in rule 441—16.2(17A). [A…

cancel or deny participation in the hawki program, the applicant or enrollee may appeal the decision in accordance with 441—Chapter 7. [ARC 9468C, IAB 8/6/25, effective 10/1/25]

benchmark, benchmark equivalent, or benefit plan that complies with Title XXI of the federal Social Security Act as amended to August 1, 2024. 86.13(1) Required medical services. The participating health plan shall cover at a minimum the following medically necessary services: a.…

86.14(1) Licensure. The participating health or dental plan must: a. Be licensed by the division of insurance of the department of insurance and financial services to provide health or dental care coverage in Iowa; or b. Be an organized delivery system licensed by the director to…

monetary donation to the hawki program, the department will deposit the donation into the hawki trust fund. The department will track all donations separately and will not commingle the donations with other moneys in the trust fund. The department shall report the receipt of all …

86.16(1) Amount subject to recovery from the enrollee or representative. The department may recover from the enrollee or the enrollee’s representative the amount of premiums incorrectly paid to a health or dental plan on behalf of the enrollee due to client error, minus any premi…

86.17(1) Eligibility. Unless otherwise specified, eligibility for supplemental dental-only coverage shall be determined in accordance with the provisions of rules 441—86.2(514I) through 441—86.12(514I) and 441—86.17(514I). 86.17(2) Premiums. Premiums for participation in the supp…

electronic data matches and information furnished by the applicant, the enrollee, or a person acting on behalf of the applicant or enrollee. A child must meet the following eligibility factors to participate in the hawki program: 86.2(1) Age. The child shall be under 19 years of …

86.3(1) Who may apply. Each person wishing to do so shall have the opportunity to apply for the hawki program in accordance with rule 441—76.1(249A). 86.3(2) Place of filing. An application for the hawki program may be filed with the department through an Internet website, by tel…

86.4(1) Hawki applicant eligible for Medicaid. At the time of initial application, if it is determined the child is eligible for Medicaid in accordance with the provisions of rule 441—75.1(249A), with the exception of meeting a spenddown under the medically needy program at 441—s…

86.5(1) Initial application. Coverage for a child who is determined eligible for the hawki program on the basis of an initial application for either hawki or Medicaid will be effective the first day of the month following the month in which the application is filed, regardless of…

to a health or dental plan using the department’s passive enrollment process. The enrollee may change plans only at the time of the annual review unless the provisions of paragraph 86.6(1)“a” or subrule 86.6(2) apply. 86.6(1) Period of enrollment. Once enrolled in a health or den…

end of the 12-month enrollment period for any of the following: 86.7(1) Age. The child shall be canceled from the hawki program as of the first day of the month following the month in which the child attained the age of 19. 86.7(2) Iowa residence abandoned. The child shall be can…

86.8(1) Income considered. The income considered in determining the premium amount will be the family’s countable income using the modified adjusted gross income methodology. 86.8(2) Premium amount. Except as specified for supplemental dental-only coverage in subrule 86.20(3), pr…

months to establish ongoing eligibility for the program. “Month one” will be the first month in which coverage is provided. 86.9(1) Review form. The department will send the family a prepopulated review form on which the answers, except for income, have been completed based on th…

“Applicant” means a person who applies for assistance under the family planning program described in this chapter. “Authorized agency” means an agency or entity with an executed memorandum of understanding (MOU) with the department authorizing the agency to perform point-of-servi…

87.10(1) Family planning providers that participate in the program can submit claims to Iowa Medicaid for services rendered no later than 45 days from the last day of the month in which services were provided. 87.10(2) Following a successful review of the claim, Iowa Medicaid wil…

87.11(1) Providers must be enrolled with the Iowa Medicaid program, subject to 441—Chapter 79, and otherwise qualified to provide family planning services under Medicaid, subject to the limitations related to abortions, as specified above under subrule 87.7(1). Effective July 1, …

provisions of this rule. 87.2(1) Persons covered. Subject to funding as described in subrule 87.7(1) and to the requirements of subrules 87.2(2), 87.2(4), and 87.2(6), assistance for family planning services will be available to the following individuals who are not enrolled in m…

87.3(1) Application. An individual who requests assistance for family planning services shall file an application on a form prescribed by the department. A woman eligible under paragraph 87.2(1)“a” is not required to file an application for assistance under this program. The depa…

purpose, assistance for family planning services under this program will be effective on the first day of the month of application or the first day of the month in which all eligibility requirements are met, whichever is later. Assistance will not be available under this program …

limited to a period of 12 months from the effective date of eligibility, or the duration of appropriated funding, whichever is less. A new application or annual redetermination of eligibility is required for benefits to continue beyond 12 months. [ARC 9819C, IAB 12/10/25, effecti…

87.6(1) Required changes to report. An individual applying for or receiving family planning services under this program shall report the following changes within ten days from the date the change is known: a. Change in mailing address; b. No longer a resident of Iowa; c. A woman …

87.7(1) Distribution of funds. Distribution of family planning services program funds shall be made to eligible, approved, and participating family planning providers subject to rule 441—87.11(217). Eligible family planning providers shall not include any provider that performs a…

this program only when care is received at or authorized by a participating family planning provider. 87.8(1) Sterilization is a covered service subject to the limitations in 441—Chapter 78. 87.8(2) Covered services cannot include abortion services. [ARC 9819C, IAB 12/10/25, effe…

chapter, including services authorized but not provided by a participating family planning provider, can be made only to participating family planning providers on a fee schedule determined by the department. Family planning services program funds distributed in accordance with t…

“Alternate PACE service site” means a location outside a primary or alternate PACE center in which one or more PACE services are offered to PACE enrollees. “Capitation payment” means the monthly payment to PACE on behalf of each Medicaid participant for the provision of covered m…

the federal enrollment requirements stated in 42 CFR 460.152 through 460.156 as amended to August 1, 2024. 88.10(1) Eligibility for Medicaid members. To enroll in a PACE program as an Iowa Medicaid member, a person must meet the eligibility requirements specified in this subrule.…

88.11(1) Records. A PACE organization shall maintain clinical and fiscal records in accordance with federal and state requirements, including but not limited to rule 441—79.3(249A) and 42 CFR 460.200 as amended to August 1, 2024. 88.11(2) Content of individual treatment record. A…

organization and its subcontractor shall protect each participant’s privacy in accordance with the confidentiality requirements stated in 45 CFR Parts 160 and 164 as amended to August 1, 2024. The PACE organization must report any HIPAA breach by the organization or its subcontra…

88.13(1) Medicaid capitation payments to the PACE organization. Under a three-way agreement, the department will make a prospective capitation payment to the PACE organization. a. The amount of the capitation payment: (1) Will be an actuarially sound rate determined in accordance…

88.14(1) The PACE program shall comply with federal and state monitoring requirements described in 42 CFR Part 460, Subpart K, as amended to August 1, 2024. 88.14(2) Within 30 days of issuance of review results, the PACE organization shall develop and implement a corrective actio…

establishes the state’s process for a potential PACE organization seeking department support and an assurance letter to provide to CMS to establish a new or expanding PACE organization. 88.2(1) Submission of letter of intent. A person authorized to act on behalf of an entity seek…

by the department and CMS to be a PACE organization must enter into an agreement with CMS and the department that meets the requirements in 42 CFR Part 460, Subpart C, as amended to August 1, 2024. [ARC 9280C, IAB 5/14/25, effective 7/1/25]

effectively and efficiently to maintain the highest physical, mental, and psychosocial well-being of each participant. 88.4(1) Licensure. Covered services shall be provided by personnel who are licensed, endorsed, registered, recognized, or qualified and who are acting within the…

plan designed to provide a safe, sanitary, and conformable environment to help prevent the transmission of disease and infection pursuant to 42 CFR 460.74 as amended to August 1, 2024. [ARC 9280C, IAB 5/14/25, effective 7/1/25]

maintained to protect the health and safety of participants, personnel, and the public pursuant to 42 CFR 460.72 as amended to August 1, 2024. [ARC 9280C, IAB 5/14/25, effective 7/1/25]

88.7(1) Required services. The PACE organization shall provide a benefit package for all participants, regardless of the source of payment, which must include the following pursuant to 42 CFR Part 460, Subpart F, as amended to August 1, 2024: a. All Medicare-covered items and ser…

88.8(1) Use of services. The PACE organization shall have a process and procedure to orient participants on how to access and request services and supports. 88.8(2) Participant rights. The PACE organization shall have a written participant bill of rights and inform participants u…

procedures for identifying and processing service determination requests, grievances, and appeals in accordance with 42 CFR 460.120 through 460.124 as amended to August 1, 2024. 88.9(1) Written log. The PACE organization must maintain a written log of all grievances and appeals, …

“Fair market value” means the price for which property or an item could have been sold on the open market at the time of transfer. “Medical assistance” means the same as defined in Iowa Code section 249F.1. “Property” means the same as defined in Iowa Code section 702.14. “Transf…

249F are not subject to Iowa Code chapter 17A. Review by the district court shall be an original hearing before the district court. [ARC 9313C, IAB 5/28/25, effective 8/1/25] These rules are intended to implement Iowa Code chapter 249F. [Filed 1/12/94, Notice 11/10/93—published 2…

89.2(1) Transfer of property. Except as provided in rule 441—89.3(249F), any transfer of property for less than fair market value creates a debt due and owing to the department from the transferee if: a. The transfer is made while the transferor is receiving medical assistance or…

section 249F.1(3)“b” that occur on or after July 1, 1996, do not create a debt to the department. [ARC 9313C, IAB 5/28/25, effective 8/1/25]

made while the transferor is receiving medical assistance or within five years prior to an application for medical assistance is presumed to be made with the intent, on the part of the transferee, of enabling the transferor to obtain or maintain eligibility for medical assistance…