Iowa Department of Human Services Terry E. Branstad Governor

Kim Reynolds Lt. Governor

Charles M. Palmer Director

April 6, 2012 GENERAL LETTER NO. 6-AP-104 ISSUED BY:

Bureau of Financial, Health and Work Supports Division of Adult, Children and Family Services

SUBJECT:

Employees’ Manual, Title 6, INCOME MAINTENANCE PROGRAMS APPENDIX, Contents (pages 1, 2, 6, and 10), revised; pages 169, 215, 315, and 404, revised; pages 68a and 214a, new; and the following forms: 470-0487 470-0487(S) 470-3948 470-4542 470-4194 470-4194(S) 470-4364 470-4364(S) 470-4364(M) 470-4364(MS) 470-2527 470-0479 470-4832 470-0480

Appeal and Request for Hearing, revised Appeal and Request for Hearing (Spanish), revised Designation of Personal Representative, new IowaCare Insurance Information Request, revised IowaCare Premium Agreement, revised IowaCare Premium Agreement (Spanish), revised IowaCare Renewal Application, revised IowaCare Renewal Application (Spanish), revised IowaCare Renewal Application (manual), revised IowaCare Renewal Application (manual Spanish), revised MAC Income Worksheet, revised Noncooperation Notice, revised Redetermination to Other Medical Programs, revised Refugee Referral to IWD and to Refugee Services, revised Comm. 20 Your Guide to Medicaid, revised Comm. 20(S) Your Guide to Medicaid (Spanish), new RC-0018 Supplemental Security Income Payment Standards, revised RC-0033 Desk Aid, revised Summary This chapter is revised to:

♦ Add a checkbox for child abuse appeals on forms 470-0487 and 470-0487(S), Appeal and Request for Hearing. The instructions have been updated to reflect availability of the English form. ♦ Add form 470-3948, Designation of Personal Representative, for quick access by staff. This form is also found in 1-C Appendix.

1305 E. Walnut Street, Des Moines, IA 50319-0114

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♦ Update form 470-4542, IowaCare Insurance Information Request, to: • •

Add a question regarding health insurance provided by an employer. Update the letterhead to reflect the Department’s branding.

♦ Update the federal poverty levels effective April 1, 2012, on the following forms: • • • • • •

470-4194, IowaCare Premium Agreement 470-4194(S), IowaCare Premium Agreement (Spanish) 470-4364, IowaCare Renewal Application 470-4364(S), IowaCare Renewal Application (Spanish) 470-4364(M), IowaCare Renewal Application (manual) 470-4364(MS), IowaCare Renewal Application (manual Spanish)

♦ Change the instructions for form 470-4194 and 470-4194(S), IowaCare Premium Agreement, to: • •

Clarify an applicant’s income must be above 150% of the federal poverty level. Eliminate the need for a control copy in the case record.

♦ Update form 470-2527, MAC Income Worksheet, to: • •

Reflect the 2012 federal poverty guidelines. Reflect the Department’s branding.

♦ Update the instructions and form 470-0479, Noncooperation Notice, to: •

Show all household members who are sanctioned.

•

Reflect the Food Assistance policy change that the noncooperation sanction follows the person from household to household.

♦ Change form 470-4832, Redetermination to Other Medical Programs, to: •

Revise information provided under the Medically Needy, IowaCare, and Medicaid for Employed People with Disabilities programs.

•

Allow the worker the option to send an IowaCare Premium Agreement, form 470-4194, when needed, or not to send form 470-4194 when it is not required.

•

Update information provided under the Iowa Family Planning Network program to:

 

Reflect eligibility expansion to persons ages 12 through 54. Replace “women” with “persons” to reflect eligibility expansion to cover men.

♦ Update the instructions to reflect availability of form 470-0480, Refugee Referral to IWD and to Refugee Services. Form 470-0480 is revised to: • •

Change the Bureau of Refugee Services address. Reflect the Department’s branding.

♦ Update Comm. 20, Your Guide to Medicaid, to: • • •

Reflect policy changes. Develop a more reader-friendly book. Include health literacy components.

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Members receive the Comm. 20 booklet when IM workers send out new packets and the IME Member Services Unit offers to send these to members on an as needed basis. A Spanish version of Comm. 20 has been added.

♦ Revise RC-0018, Supplemental Security Income Payment Standards, to update the SSI-related Medicaid and State Supplementary Assistance income limits due to the Social Security and SSI cost-of-living increases effective January 1, 2012. ♦ Revise RC-0033, Desk Aid, to update the Medicare premiums and increased SSIrelated income limits due to the Social Security and SSI cost-of-living increases effective January 1, 2012. Effective Date Upon receipt. Material Superseded This material replaces the following pages from Employees’ Manual, Title 6, Appendix: Page

Date

Contents (pages 1 and 2) Contents (page 6) Contents (page 10) 470-0487 470-0487(S) 470-4542 470-4194 470-4194(S) 169 470-4364 470-4364(S) 470-4364(M) 470-4364(MS) 470-2527 470-0479 215 470-4832 470-0480 315 404 Comm. 20 RC-0018 RC-0033

October January October 11/10 11/10 1/11 6/11 6/11 October 10/11 10/11 10/11 10/11 4/11 6/03 October 1/11 1/10 October October 5/10 4/10 10/11

7, 2011 6, 2012 7, 2011

7, 2011

7, 2011 7, 2011 7, 2011

Additional Information Destroy existing supplies of form 470-0480, Refugee Referral to IWD and to Refugee Services. The form will no longer be printed.

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Destroy existing supplies of Comm. 20 and Comm. 20(S), Your Guide to Medicaid. Order supplies of Comm. 20 or Comm. 20(S), dated 1/12, from Anamosa in the usual manner. Refer questions about this general letter to your area income maintenance administrator.

Title 6: Income Maintenance Programs Appendix Revised April 6, 2012

TABLE OF CONTENTS Page 1

Page ABAWD Letter, Form 470-3967 or 470-3967(S) ..................................................... 1 Absent Parent Information, Form 470-3773 or 470-3773(S) .................................... 2 Addendum to Application and Review Forms for Release of Information, Form 470-4670 or 470-4670(S) .............................................................................. 3 Addendum to Application for Help with Medicare Prescription Drug Plan Costs, Form 470-4167 ............................................................................................. 5 Adding an EBT Cardholder, Form 470-3983 or 470-3983(S) ..................................... 6 Adjustment to Overpayment Balance, Form 470-0010............................................. 8 Affidavit and Agreement for Issuance of Duplicate Warrant, Form 470-0005.............. 10 Affidavit as to Forged Endorsement, Form 470-0004 .............................................. 11 Affidavit Concerning Documentation of Citizenship, Form 470-4374 or 470-4374(S) ... 13 Affidavit of Citizenship, Form 470-4373 or 470-4373(S) ......................................... 14 Affidavit of Identity, Form 470-4386 or 470-4386(S) ............................................. 15 Agreement for Automatic Deposit, Form 470-0261 ................................................ 16 Agreement for Telephone Hearing, Form 427-0415 or 427-0415(S) ......................... 17 Agreement to Pay a Debt, Form 470-0495 or 470-0495(S) ..................................... 18 Agreement to Sell Excess Property, Form 470-2909 ............................................... 19 Annuity Release of Information, Form 470-4699.................................................... 21 Appeal and Request for Hearing, Form 470-0487 or 470-0487(S) ............................ 22 Application for Extra Help with Medicare Prescription Drug Plan Costs, Form SSA-1020B-OCR-SM .....................................................................................25 Approval of Release of Information by Iowa Department of Human Services, Form 470-1363 ............................................................................................26 Attribution of Resources Appeal Summary, Form 470-3144 ..................................... 27 Authorization for Examination and Claim for Payment, Form 470-0502 ..................... 29 Authorization for Release of Information, Form 470-0461 or 470-0461(S)................. 30 Authorization to Disclose Information to the Iowa Department of Human Services, Form 470-4459 or 470-4459(S) ........................................................ 32 Authorization to Obtain or Release Health Care Information, Form 470-3951 or 470-3951(S) ...............................................................................................35 Bank or Credit Union Information, Form 470-1631 or 470-1631(S) .......................... 39

Iowa Department of Human Services Employees’ Manual

Title 6: Income Maintenance Programs Appendix Revised April 6, 2012

TABLE OF CONTENTS Page 2

Page Billing Statement, Form 470-0130 ....................................................................... 41 Cancellation of Premium Payment, Form 470-2846 ................................................ 42 Care for Kids, Form 470-0365.............................................................................43 Case Activity Report, Form 470-0042................................................................... 44 Certificate of Enrollment, Form 470-4444 ............................................................. 46 Certification of Eligibility of SSI Applicant, Form 470-0363 ...................................... 47 Change in Health Insurance, Form 470-3792 ........................................................ 49 Change in Medical Deduction for Food Assistance, Form 470-4487 or 470-4487(S) .... 50 Child Care Assistance Application, Form 470-3624 or 470-3624(S) .......................... 51 Child Care Assistance Billing/Attendance, Form 470-4534 ....................................... 54 Child Care Assistance Billing/Attendance Provider Record, Form 470-4535 ................ 56 Child Care Assistance Provider Agreement, Form 470-3871 or 470-3871(S) .............. 58 Child Care Assistance Review, Form 470-4377(M) or 470-4377(S) ........................... 60 Child Care Claim Cover Letter, Form 470-4469 or 470-4469(S) ............................... 62 Child Support Information Request, Form 470-3782 .............................................. 63 Claimant’s Supplemental Statement, Form 470-0006 ............................................. 64 Daily Tip Record, Form 470-3777 ........................................................................ 65 Debt Setoff Credit, Form 470-1667...................................................................... 66 Denial of Health Insurance Premium Payment, Form 470-2847................................ 67 Description of Efforts to Sell Property, Form 470-2908 ........................................... 68 Designation of Personal Representative, Form 470-3948 ........................................ 68a DIA Referral for Transfer of Assets, Form 470-3159 ............................................... 69 Disability Report for Adults, Form 470-2465 ......................................................... 70 Disability Report for Children, Form 470-3912 ....................................................... 71 Disability Transmittal, Form 470-2472 ................................................................. 72 Disposal of Assets Penalty Notice of Decision, Form 470-4365 ................................. 75 Document Verification Request, Form G-845S ....................................................... 76 Documentation of Citizenship and Identity, Form 470-4381 .................................... 77 Documentation of Claim Determination, Form 470-0311 ......................................... 78

Iowa Department of Human Services Employees’ Manual

Title 6: Income Maintenance Programs Appendix Revised April 6, 2012

TABLE OF CONTENTS Page 6

Page Medicare Savings Programs Additional Information Request, Form 470-4846 or 470-4846(S).......................................................................................... 205 MEPD Billing Statement, Form 470-3902 ............................................................ 207 MEPD Income Worksheet, Form 470-3686 .......................................................... 208 MEPD Intent to Return to Work, Form 470-4856.................................................. 211 MEPD Refund Notice, Form 470-3743 ................................................................ 212 New Household Member, Form 470-3780 ........................................................... 213 Newborn, Form 470-3781 or 470-3781(S) .......................................................... 214 Noncooperation Notice, Form 470-0479 ............................................................. 214a Non-Law Enforcement Record Check Request Form A, 595-1489 or 595-1489(S) ..... 216 Notarized Statement for Child Support Recovery Office, Form 470-2220 ................. 218 Notice of Attribution of Resources, Form 470-2588 .............................................. 219 Notice of Cancellation/Redetermination, Form 470-3152 or 470-3152(S) ................ 220 Notice of Child Care Assistance Overpayment, Form 470-4530 .............................. 221 Notice of Child Care Assistance Provider Sanction, Form 470-4053......................... 222 Notice of Decision, Form 470-0485, 470-0485(S), 470-0486, or 470-0486(S) ......... 224 Notice of Decision: Child Care, Form 470-4558 .................................................. 229 Notice of Decision: Child Care Assistance, Form 470-3915 or 470-3915(S)............. 230 Notice of Decision for Extra Help with Medicare Prescription Drug Costs, Form 470-4199 .......................................................................................... 251 Notice of Decision for Medically Needy, Form 470-2330 ........................................ 258 Notice of Decision: Medical Assistance or State Supplementary Assistance, Form 470-0490 .......................................................................................... 261 Notice of Decision on Denied Prior Authorization, Form 470-0390 .......................... 265 Notice of Decision on Medicaid Claim, Form 470-0392 .......................................... 266 Notice of Disqualification, Form 470-0288 or 470-0288(S) .................................... 267 Notice of Employment, Form 470-0820 .............................................................. 268 Notice of Expiration, Form 470-0325 ................................................................. 270 Notice of FIP or RCA Overpayment, Form 470-4683 ............................................. 272 Notice of Food Assistance Debt, Form 470-4179 .................................................. 273

Iowa Department of Human Services Employees’ Manual

Title 6: Income Maintenance Programs Appendix Revised April 6, 2012

TABLE OF CONTENTS Page 10

Page Comm. 2 or Comm. 2(S), Facts About the Food Assistance Program ...................... 401 Comm. 4, Care for Kids ................................................................................... 402 Comm. 18, State Supplementary Assistance ....................................................... 403 Comm. 20 or Comm. 20(S), Your Guide to Medicaid ............................................ 404 Comm. 24 or Comm. 24(S), One-Time Payments ................................................ 405 Comm. 27 and Comm. 27(S), Medicaid for Families and Children........................... 406 Comm. 28 or Comm. 127 (Spanish), Medicaid for SSI-Related Persons ................... 407 Comm. 30, Medicaid for the Medically Needy ...................................................... 408 Comm. 51, Information Practices ...................................................................... 409 Comm. 52, Medicaid for People in Nursing Homes and Other Care Facilities ............. 410 Comm. 60, Medicaid for the Qualified Medicare Beneficiary ................................... 411 Comm. 62 or Comm. 62(S), Child Care Assistance............................................... 412 Comm. 69 or Comm. 69(S), Presumptive Eligibility for Pregnant Women ................ 413 Comm. 72, Protection of Your Resources and Income ........................................... 414 Comm. 84 or Comm. 84(S), Information on Emergency Service ............................ 415 Comm. 91 or Comm. 91(S), The Health Insurance Premium Payment (HIPP) Program for Iowa Medicaid Recipients ........................................................... 416 Comm. 95 or Comm. 95(S), Minimum Health and Safety Requirements .................. 417 Comm. 99, The Iowa AIDS/HIV Health Insurance Premium Payment Program ......... 418 Comm. 108, The Family Investment Program (FIP) .............................................. 419 Comm. 121 or Comm. 121(S), Important Notice to Property Owners and Renters .... 420 Comm. 123 or Comm. 123(S), Important Information for You and Your Family Members About the Estate Recovery Program ................................................ 421 Comm. 132 or Comm. 132(S), Family Planning Counseling ................................... 422 Comm. 133 or Comm. 133(S), FIP for Minor Parents ............................................ 423 Comm. 137, 60-Month Limit on FIP ................................................................... 424 Comm. 156 and Comm. 156(S), hawk-i Healthy and Well Kids in Iowa ................... 425 Comm. 156A, hawk-i Brochure Income Guidelines ............................................... 426

Iowa Department of Human Services Employees’ Manual

Iowa Department of Human Services

Appeal and Request for Hearing Fill out the top part of this form. You do not need to fill out the worker information part. Name: Last

First

Check the programs you want to appeal. Family Investment Program (FIP), Refugee Cash Assistance (RCA) or PROMISE JOBS Child Care Assistance Food Assistance Medicaid including Waivers Attribution Administrative Hearing (only for attribution appeals) Child Abuse State Supplementary Assistance Child Support Adoption or Foster Care Other (explain):

Mi

Mailing Address

City

State

Phone Number

County

(

Zip Code

)

I want my benefits to continue, if they can. I want an interpreter for my hearing. If yes, what language do you read?

Yes Yes

No No

I want a pre-hearing conference. Yes Tell us why you are appealing. Please be brief.

No

Your Signature _____________________________________

You may have to pay them back if you lose your appeal. We will provide an interpreter for you. What language do you speak?

Date ________________________________________

If you want someone to help you with your appeal, please write the person’s name and address below. This person will get information about your appeal. You are not required to list someone here. Name

Phone Number ( ) City

Mailing Address

State

Zip Code

Worker Information Worker Name

Phone Number ( )

Worker Number

County/Office

Case Number/SID Number

Will benefits continue or did you reinstate benefits because of this appeal? Yes No Appellant chose not to have benefits continue If not, why? Application/recertification Appeal not filed before the effective date Other (explain) If the consumer wants an interpreter, what language is needed? The adverse action appealed is the result of a: DDS report IFMC decision LBP PJ worker

CSC worker action Office

QC report

QC worker

Office

DIA investigation

Investigator

Office

Attach a copy of the NOD being appealed. If it isn’t attached, explain why: Tell us your vacation and training schedule for the next 3 months.

470-0487 (Rev. 2/12)

Instructions Use of this form is not mandatory. Any written appeal is a valid appeal. Verbal appeals are valid only in the Food Assistance program. The worker receiving the Food Assistance appeal should record verbal appeals on this form. Be sure to indicate that this is a verbal appeal. Also, include the date the appeal was requested. If you get a letter stating the consumer wants to appeal, attach the letter to this form. You need to fill in the consumer’s information and your information. If you do not know what the consumer is appealing, you need to indicate what you think the appeal is about. The DHS Appeals Section will ask the consumer for additional information, if necessary. Do not hold an appeal if you need to get additional information from the consumer. On the front of this form, date-stamp all appeals on the date they are received in your office. If you got the appeal in the mail, keep the postmarked envelope and attach it to this form. Attach a copy of the Notice of Decision that the consumer appealed to this form. Send this to: Department of Human Services Appeals Section, 5th Floor 1305 E Walnut St Des Moines, IA 50319-0114 Send in an appeal summary to the DHS Appeals Section within 10 calendar days of the date the appeal was filed. Do not delay sending in an appeal while you work on your appeal summary. Send all new appeals to the DHS Appeals Section within one working day of receipt. Be sure to include the Notice of Decision and the postmarked envelope, if applicable. Use local mail if available. If the appellant requests that benefits continue, but the appellant does not meet the criteria listed in Employees’ Manual 1-E, then issue a manual notice of decision stating that the appellant’s request for continuation of benefits while an appeal is pending is denied. The appellant has the right to appeal this action also. Be sure to indicate your vacation and training schedule for the next 3 months. This will be used when scheduling a hearing. For more information about appeals, check out the Appeals Section intranet site at http://dhsintranet/appeals/

470-0487 (Rev. 2/12)

Iowa Department of Human Services

Appeal and Request for Hearing (Apelación y Solicitud de Audiencia) Complete la mitad superior de este formulario. No es necesario que llene la sección con los datos del trabajador. Identificación: Apellidos

Primer Nombre

Segundo nombre

Ciudad

Estado

Codigo postal

Número de teléfono

Condado

Marque los programas a los que desea apelar. Family Investment Program (Inversión familiar, FIP), Refugee Cash Assistance (Asistencia en efectivo para refugiados, RCA) o PROMISE JOBS Child Care Assistance (Asistencia de cuidado infantil) Food Assistance (Asistencia en alimentos) Medicaid incluyendo Waivers (servicios de exención) Atribución Audencia administrativa (solo para apelaciones de atribución Abuso Infantil State Supplementary Assistance (Asistencia estatal complementaria) Child Support (Manutención de menores) Adopción o familia sustituta Otro (explicar):

Dirección postal

(

)

Si es posible, deseo que mis beneficios continúen. Deseo la asistencia de un intérprete durante la audencia En caso afirmativo, ¿qué idioma lee usted?

Sí

No

Sí

No

Deseo una conferencia previa a la audiencia. ¿Cuál es el motivo de su apelación? Sea breve.

Sí

Si usted pierde esta apelacion, es posible que deba rembolsar el costo de dichos beneficios. Se le proporcionara la asistencia de un intérprete. ¿Qué idioma habla usted?

No

Firma ____________________________________________ Fecha _______________________________________ Si desea contra con la ayuda de alguna persona durante esta apelación, anote su nombre y dirección en los campos siguientes y esa persona podrá recibir información acerca del proceso. No es obligación que designe a alguien. Nombre

Número de teléfono ( ) Ciudad

Dirección postal

Estado

Código postal

Worker Information (Información del trabajador) Worker Name Worker Number

Phone Number ( ) County/Office

Case Number/SID Number

Will benefits continue or did you reinstate benefits because of this appeal? Yes No Appellant chose not to have benefits continue If not, why? Application/recertification Appeal not filed before the effective date Other (explain) If the consumer wants an interpreter, what language is needed? The adverse action appealed is the result of a: DDS report IFMC decision LBP PJ worker Q.C. report QC worker DIA investigation Investigator

CSC worker action

Attach a copy of the NOD being appealed. If it isn’t attached, explain why: Tell us your vacation and training schedule for the next 3 months. 470-0487(S) (Rev. 2/12)

Office Office Office

Instructions Use of this form is not mandatory. Any written appeal is a valid appeal. Verbal appeals are valid only in the Food Assistance program. The worker receiving the Food Assistance appeal should record verbal appeals on this form. Be sure to indicate that this is a verbal appeal. Also, include the date the appeal was requested. If you get a letter stating the consumer wants to appeal, attach the letter to this form. You need to fill in the consumer’s information and your information. If you do not know what the consumer is appealing, you need to indicate what you think the appeal is about. The DHS Appeals Section will ask the consumer for additional information, if necessary. Do not hold an appeal if you need to get additional information from the consumer. On the front of this form, date-stamp all appeals on the date they are received in your office. If you got the appeal in the mail, keep the postmarked envelope and attach it to this form. Attach a copy of the Notice of Decision that the consumer appealed to this form. Send this to: Department of Human Services Appeals Section, 5th Floor 1305 E Walnut St Des Moines, IA 50319-0114 Send in an appeal summary to the DHS Appeals Section within 10 calendar days of the date the appeal was filed. Do not delay sending in an appeal while you work on your appeal summary. Send all new appeals to the DHS Appeals Section within one working day of receipt. Be sure to include the Notice of Decision and the postmarked envelope, if applicable. Use local mail if available. If the appellant requests that benefits continue, but the appellant does not meet the criteria listed in Employees’ Manual 1-E, then issue a manural notice of decision stating that the appellant’s request for continuation of benefits while an appeal is pending is denied. The appellant has the right to appeal this action also. Be sure to indicate your vacation and training schedule for the next 3 months. This will be used when scheduling a hearing. For more information about appeals, check out the Appeals Section intranet site at http://dhsintranet/appeals/

470-0487(S) (Rev. 2/12)

Iowa Department of Human Services

Designation of Personal Representative Name of Client

Date of Request

Mailing Address – Street or P.O. Box

Social Security Number, Patient Number, or State ID

City, State, and Zip Code

Phone Number

Check all of the programs that apply:

Medicaid

hawk-i

Birth Date

Facility

To be completed by client I designate ____________________________________ to act as my personal representative. (Name of Person)

Relationship of personal representative to client: Son or daughter Spouse Friend Attorney Other (Please specify) _____________________________________________________ Client’s Signature

470-3948 (Rev. 12/11)

Date

Copy 1 – Client

Copy 2 – File

Title 6: Income Maintenance Programs Appendix April 6, 2012

Page 68a Designation of Personal Representative 470-3948

Designation of Personal Representative, Form 470-3948 Purpose

Clients may use form 470-3948 to designate a personal representative. A “personal representative” is someone designated by another as standing in the other’s place or representing the other’s interest for one or more purposes.

Source

Print this form from the DHS Intranet eForms web page.

Completion

The client wanting to use this form to designate a personal representative completes the form and gives or sends it to: ♦ The income maintenance worker, ♦ The Department’s Security and Privacy Office, or ♦ A facility privacy official. NOTE: Use of this form is not mandatory. A client may write a letter designating a personal representative. If you know the client, the client may also verbally inform you of the client’s choice of personal representative and you can document the client’s choice in the case file.

Distribution

Give a copy of the form to anyone requesting it. File the form in the case record.

Data

The client completes the needed information and signs the form. You will not need to enter any information.

Iowa Department of Human Services Employees’ Manual

Iowa Department of Human Services Terry E. Branstad Governor

Kim Reynolds Lt. Governor

Charles M. Palmer Director

Dear  The Department of Human Services has received a report that you have health insurance through ______________________________. Please provide the following information by BBBBBBBBBBBBBBBBBB.  If we don't get the information by this date, then your IowaCare benefits may be canceled. Is this health insurance from your employer?      If not, explain how you are getting this health insurance.      ____________________________________________

 Yes

 No

Does your health insurance cover pre­existing conditions?

 Yes

 No

Are services you need from IowaCare covered by your health insurance?

 Yes

 No

Does your health insurance have a limit on benefits?      If yes, have you reached that limit?

 Yes  Yes

 No  No

Additional comments:  ________________________________________________ __________________________________________________________________ __________________________________________________________________ If you have any questions or need more time to get the information, please call me on or before BBBBBBBBBBBBBBBBBB. Sincerely,

470­4542  (Rev. 4/12)

Iowa Department of Human Services

IowaCare Premium Agreement Instructions: All adults in your household who are applying for IowaCare must read and sign this form. If you have questions, please contact your income maintenance worker before signing the form. See the premium chart on the back of this form to find out if you will have to pay a premium. If you have a premium, it must be paid every month to keep getting IowaCare to pay your medical bills. Or, if you don’t have enough money to pay the monthly premium, then you must tell us by sending the bill back with a hardship request by the due date. I understand that if I am approved for IowaCare, I may have to pay a monthly premium. I also understand: •

An IowaCare Billing Statement will be sent for each month that a premium must be paid.

•

If I am not already on IowaCare and I owe a premium, the first premium will not be due until the month after a decision is made on my application.

•

If this is an application to continue getting IowaCare and if I owe a premium, a premium will be paid for each month of the new certification period.

•

I must return the billing statement with my full premium payment or claim hardship each month, even if I do not get medical care in those months.

•

If I owe a premium, I agree to either pay the premium or claim hardship for a minimum of four months, even if IowaCare stops before the end of these four months.

•

If I do not pay my premium or claim hardship by the due date on the billing statement, IowaCare will stop paying for my medical care after 60 days.

•

If I do not pay my premium or claim hardship by the due date, I will still owe the Department of Human Services (DHS) any unpaid premiums. When the premiums are overdue by 60 days, the premium amount will become a legal debt that DHS may collect by any means allowed by law. Print names of all persons applying for IowaCare

Signature or mark of person applying for IowaCare

Today’s date

Signature or mark of any other adult applying for IowaCare

Today’s date

Signature of person, if any, who helped complete the form

Today’s date

470-4194 (Rev. 4/12)

Some IowaCare members must pay a premium to get IowaCare. To find out if you will have to pay a premium, add the income from all family members in your home. Look at the Family Size chart below. If your family income is above the amount for the family size, then you will have to pay a premium. Family size 150% FPL = Monthly income of

1

2

3

4

5

6

$1,397

$1,892

$2,387

$2,882

$3,377

$3,872

If you are the only one in your household who wants IowaCare, the premiums are shown in the One IowaCare Member column. If there are two or more people in your household who want IowaCare, the joint premiums are shown in the Two or More Members column. Joint premiums mean that all the IowaCare members in one household pay only one premium together. Premium Chart One IowaCare member and income is at or below the FPL of:

Member’s premium amount is:

Two or more members and income is at or below the FPL of:

Member’s joint premium amount is:

150% = $1,397

No cost

150% = $1,892

No cost

160% = $1,490

$51

160% = $2,018

$69

170% = $1,583

$55

170% = $2,144

$73

180% = $1,676

$58

180% = $2,270

$78

190% = $1,769

$61

190% = $2,396

$82

200% = $1,862

$65

200% = $2,522

$86

470-4194 (Rev. 4/12)

Iowa Department of Human Services

IowaCare Premium Agreement (Contrato de prima de IowaCare) Instrucciones: Todos los adultos de su hogar que solicitan IowaCare deben leer y firmar este formulario. Si tiene alguna pregunta, por favor contacte a su asistente de mantenimiento del ingreso antes de firmar el formulario. Consulte el cuadro de primas que se encuentra al dorso de este formulario para saber si deberá pagar una prima. Si tiene una prima, debe pagarla todos los meses para que IowaCare siga pagando sus facturas médicas. O bien, si no tiene dinero suficiente como para pagar la prima mensual, debe comunicárnoslo devolviendo la factura junto con una solicitud por dificultades económicas antes de la fecha de vencimiento. Entiendo que, si soy aprobado para recibir IowaCare, es posible que deba pagar una prima mensual. También entiendo que: •

Se le enviará una Factura de IowaCare por cada mes en que deba pagarse una prima.

•

Si no participo actualmente de IowaCare y adeudo una prima, la primera prima no será pagadera hasta el mes siguiente a la fecha en que se tome una decisión sobre mi solicitud.

•

Si ésta es una solicitud para continuar obteniendo IowaCare y adeudo el pago de una prima, se pagará una prima por cada mes correspondiente al nuevo período de certificación.

•

Debo devolver mi factura con el pago completo de mi prima o reclamar una exención por dificultades económicas cada mes, incluso si no recibo atención médica durante esos meses.

•

Si debo una prima, acepto que debo pagar la prima o reclamar una exención por dificultades económicas por un mínimo de cuatro meses, incluso si IowaCare finaliza antes de que transcurra la totalidad de esos cuatro meses.

•

Si no pago mi prima o reclamar una exención por dificultades económicas para la fecha de vencimiento de la factura, IowaCare dejará de pagar mi atención médica luego de transcurridos 60 días.

•

Si no pago mi prima o reclamar una exención por dificultades económicas para la fecha de vencimiento, seguiré adeudándole al Department of Human Services (DHS) las primas impagas. Pasados 60 días de la fecha de vencimiento de las primas, el monto de la prima se convertirá en una deuda legal que el DHS puede cobrar por cualquier medio que la ley autorice. Nombres en letra de imprenta de todas las personas que solicitan IowaCare

Firma o marca del solicitante de IowaCare

Fecha de hoy

Firma o marca de cualquier otro adulto que solicita IowaCare

Fecha de hoy

Si corresponde, firma de la persona que ha ayudado a completar el formulario

Fecha de hoy

470-4194(S) (Rev. 4/12)

Algunos miembros de IowaCare deben pagar una prima para acceder a IowaCare. Para averiguar si debe pagar una prima, añada los ingresos de todas las personas que integran su hogar. Preste atención al cuadro de Tamaño de la Familia que se encuentra debajo. Si los ingresos de su familia son superiores a los estipulados para el tamaño de la familia, deberá pagar una prima. Tamaño de la familia 150% del Nivel Federal de Pobreza (FPL) = Ingresos mensuales de

1

2

3

4

5

6

$1.397

$1.892

$2.387

$2.882

$3.377

$3.872

Si usted es la única persona de su hogar que desea acceder a IowaCare, las primas se muestran en la columna correspondiente a Un miembro de IowaCare. Si dos o más personas de su hogar desean acceder a IowaCare, las primas conjuntas se muestran en la columna correspondiente a Dos o más miembros. Las primas conjuntas significan que todos los miembros de IowaCare de un hogar pagan una sola prima común. Cuadro de primas Un miembro de IowaCare y un ingreso equivalente o menor al Nivel Federal de Pobreza (FPL) de:

El monto de la prima del miembro es de:

Dos o más miembros y un ingreso equivalente o menor al Nivel Federal de Pobreza (FPL) de:

El monto de la prima conjunta del miembro es de:

150% = $1.397

Sin costo

150% = $1.892

Sin costo

160% = $1.490

$51

160% = $2.018

$69

170% = $1.583

$55

170% = $2.144

$73

180% = $1.676

$58

180% = $2.270

$78

190% = $1.769

$61

190% = $2.396

$82

200% = $1.862

$65

200% = $2.522

$86

470-4194(S) (Rev. 4/12)

Title 6: Income Maintenance Programs Appendix Revised April 6, 2012

Page 169 IowaCare Premium Agreement 470-4194 or 470-4194(S)

IowaCare Premium Agreement, Form 470-4194 or 470-4194(S) Purpose

Any applicant who has applied for IowaCare using a form other than the IowaCare Application, Comm. 239, or 470-4364, IowaCare Renewal Application, and has income above 150% of the federal poverty level, must sign and return this form to certify that the applicant understands and agrees: ♦ To pay a premium based on the applicant’s income for each month the applicant receives IowaCare coverage. ♦ That the first four months premiums are required, even if coverage under IowaCare ends before the end of the four months. ♦ That the applicant owes any unpaid premium amounts, which will become a legal debt that the Department may collect by any means allowed by law.

Source

Complete the English or Spanish version of the form on line using the template available on the DHS Intranet eForms web page.

Completion

When an IowaCare application was filed using any form other than the Comm. 239, IowaCare Application, or 470-4364, IowaCare Renewal Application, and has income above 150% FPL, the applicant must complete and return the form before approval of IowaCare.

Distribution

Send the original IowaCare Premium Agreement statement to the applicant along with the IowaCare Premium Agreement Cover Letter. Enclose an envelope for the applicant to use to return the form to the scanning center. Allow 10 days for the signed IowaCare Premium Agreement statement to be returned.

Data

This form is self-explanatory.

Iowa Department of Human Services Employees’ Manual

Iowa Department of Human Services

Iowa Department of Human Services

IowaCare Renewal Application

County Number:

Worker Name:

Case Number:

Phone No.

It’s time for the yearly renewal of your IowaCare coverage. In order to renew your IowaCare, you need to answer all of the questions on the application below. If you have any questions or need help filling out this form, please call 1-800-338-8366. If you live in the Des Moines area, you can call 515-256-4606. Important: Please make sure to sign your name on page 3. Please use only blue or black ink. Mail the application before You will get a letter letting you know if your IowaCare coverage is renewed.

Tell Us About You Name

Telephone Number

Street Address

Mailing Address (if different)

City

State

Zip Code

People in Your Home List all the people in your home, including yourself, and mark yes or no if you are applying for that person. Please use another piece of paper, if needed. Apply for? Yes/No

Name (First, Last)

Sex M/F

Relationship to You

Birth Date

Social Security Number

Race

Optional

Self

List anyone in your home who is disabled: List anyone in your home who is pregnant: Due Date If you have unpaid medical bills, please include a copy of the bills you still owe. Do you have any unpaid bills from last month?

Yes

If yes, write down where you owe the bills.

470-4364 (Rev. 2/12) H4364A

Page 1

No

Citizen Yes/No

If Alien, Status

Income You must tell us all of the money the people in your household get or expect to get. If you leave a space blank, that means you don’t get that money. If self-employed, give your annual net profit, which is gross income minus the cost of business expense except depreciation and capital expenses. If off work temporarily, estimate your annual income. Use another piece of paper, if needed. Who is your employer? Where the Money Comes From

Who Gets the Money

Amount

Monthly or Yearly

Money from Work Before Taxes (Gross) Self-Employment or Odd Jobs (Annual income) Tips Unemployment or Worker’s Comp (Gross) Social Security or SSI (Gross) Veterans Benefits, Pensions or Retirement Child Support or Alimony Money from Friends or Relatives Other (including lump sum):

Resources or Assets A resource or asset is cash or anything that can be changed to cash. List all of your resources or assets and the amount or value. This includes items like cash on hand, checking accounts, vehicles, life insurance, stocks, bonds, certificates of deposits (CDs), trust funds, retirement accounts, burial contracts, and burial spaces. If you leave a space blank, we will take that to mean that you have no resources or assets. Person with Resource

Type of Resource

Amount or Value

Location of Resource

Health Insurance You must answer yes or no to the following questions. Does anyone have Medicare?

Yes

No

Who?

Does anyone have other health insurance?

Yes

No

Who?

Does your employer offer health insurance?

Yes

No

Who?

If you have kids, are they covered by the Healthy and Well Kids in Iowa (hawk-i) program?

Yes

No

If yes, how much is your hawk-i premium?

$10

470-4364 (Rev. 2/12) H4364B

Page 2

$20

$15 (dental only)

Social Security Information I must give the social security numbers for everyone who wants IowaCare. This is required by Section 1137(a)(1) of the Social Security Act and 42 CFR 435.910. We use social security numbers to:

•

Check income, eligibility, and IowaCare payments.

•

Determine a person’s right to IowaCare.

•

Comply with federal law.

•

Match records with other agencies.

Your Signature and Understanding I certify, under penalty of perjury, that:

•

The answers I gave are correct and complete to the best of my knowledge.

•

My answer about citizenship or alien status of each person applying for assistance is correct.

I understand that if I am approved for IowaCare, I may have to pay a monthly premium or claim hardship in order to get coverage. I also understand:

•

I will be sent a billing statement for each month that I owe a premium.

•

I agree to assign medical payments from a third party to the Medicaid agency for myself and others who are eligible for Medicaid for whom I legally can assign benefits. I also agree to cooperate in obtaining medical payments from third parties.

•

If I am not already on IowaCare and I owe a premium, premiums will not be due until the month after a decision is made on my application. If this is an application to continue IowaCare and if I owe a premium, a premium will be due for each month of the new enrollment period.

•

I must return the billing statement with my payment or claim hardship each month, even if I do not get medical care in those months. This statement must be postmarked no later than the due date on the billing statement.

•

If I owe a premium, I agree to either pay the premium or claim hardship for a minimum of four months, even if IowaCare stops before the end of these four months.

•

If I do not pay my premium or claim hardship by the due date on the billing statement, my IowaCare benefits will stop.

•

If I do not pay my premium or claim hardship by the due date, I will owe DHS any unpaid amount. This unpaid amount will become a legal debt that DHS may collect by any means allowed by law.

Signature or Mark of IowaCare member

Today’s Date

Signature or Mark of second IowaCare member (if applies)

Today’s Date

Signature of Person, If Any, Who Helped Complete the Form

Today’s Date

470-4364 (Rev. 2/12) H4364C

Page 3

Use this sheet to list income not shown in the Income section and any comments.

470-4364 (Rev. 2/12) H4364D

Page 4

Keep this part for your records How Much Will It Cost? You may need to pay a premium to get IowaCare. The amount of your premium is based on the amount of money you get each month. If you owe a premium, it is due at the end of each month. You will be responsible for at least four months of premiums. IowaCare coverage may stop if you don’t pay your monthly premium or claim hardship.

Premium Amounts You may have to pay a premium to get IowaCare. To find out if you will have to pay a premium, add the income from all the family members in your home. Look at the family size chart below. If your family income is above the amount for the family size, then you will have to pay a premium. Family Size 150 % of FPL = Monthly income of

1

2

3

4

5

6

$1,397

$1,892

$2,387

$2,882

$3,377

$3,872

If you are the only one in the household who wants IowaCare, the premiums are shown in the One IowaCare Member column. If there are two or more people in your household who want IowaCare, the joint premiums are shown in the Two or More Members column. Joint premiums mean that all the IowaCare members in one household pay only one premium together. Premium Chart One IowaCare Member

Two or more members and income is at or below the FPL of:

And income is at or below the FPL of:

Member’s premium amount is:

150%=$1,397

No cost

150%=$1,892

No cost

160%=$1,490

$51.00

160%=$2,018

$69.00

170%=$1,583

$55.00

170%=$2,144

$73.00

180%=$1,676

$58.00

180%=$2,270

$78.00

190%=$1,769

$61.00

190%=$2,396

$82.00

200%=$1,862

$65.00

200%=$2,522

$86.00

Member’s joint premium amount is:

Information on Immigration Status You can apply for part of your household even if some members do not have legal immigrant status. You may need to give proof of immigration status for the people who are not U.S. citizens or nationals. Your household’s alien status may be checked through the Citizenship and Immigration Service. Any information we get from the Citizenship and Immigration Service may affect what your household may get. We will not contact the Citizenship and Immigration Service about the people you don’t apply for. However, we may use their income and resources to see if the rest of the household can get help.

470-4364 (Rev. 2/12) H4364E

Page 5

Keep this part for your records Changes to Report Report changes to DHS within 10 calendar days from the date the change happens. This includes changes in:

• • • •

Mailing address Health insurance coverage Moving out of Iowa Entering a non-medical institution

You do not need to report the following:

• • •

Changes in your income Someone moves in or out of your home Changes in resources or assets

You Have the Right to Appeal You, or the person helping you, may request an appeal hearing if you do not agree with any action taken on your case. You must appeal in writing. To appeal in writing, do one of the following:

• • •

Fill out an appeal electronically at https://dhssecure.dhs.state.ia.us/forms/, or Write a letter telling us why you think a decision is wrong, or Fill out an Appeal and Request for Hearing form, which you can get from your county DHS office.

Send or take your appeal to the Department of Human Services, Appeals Section, 5th Floor, 1305 E Walnut Street, Des Moines, Iowa 50319-0114. If you need help filing an appeal, ask your local DHS office. You can represent yourself. Or, you can have a friend, relative, lawyer or someone else act on your behalf. You may contact your local DHS office about legal services. You may have to pay for these legal services. If you do, your payment will be based on your income. You may also call Iowa Legal Aid at (800) 532-1275. If you live in Polk County, call (515) 243-1193.

You Will Not Be Discriminated Against Policy Regarding Discrimination, Harassment, Affirmative Action and Equal Employment Opportunity It is the policy of the Iowa Department of Human Services (DHS) to provide equal treatment in employment and provision of services to applicants, employees and clients without regard to race, color, national origin, sex, sexual orientation, gender identity, religion, age, disability, political belief or veteran status. If you feel DHS has discriminated against or harassed you, please send a letter detailing your complaint to: Iowa Department of Human Services, Office of Human Resources, Hoover Building – 1st Floor, 1305 E. Walnut, Des Moines, IA 50319-0114; fax (515) 281-4243 or via e-mail [email protected]

470-4364 (Rev. 2/12) H4364F

Page 6

Iowa Department of Human Services Iowa Department of Human Services

IowaCare Renewal Application (Solicitud Renovación de IowaCare)

Número del condado:

Nombre del trabajador:

Número de caso:

Teléfono

Es hora de la renovación anual de su cobertura de IowaCare. A fin de renovar su IowaCare, debe responder todas las preguntas de la solicitud que se encuentra a continuación. Si tiene preguntas o necesita ayuda para llenar este formulario, por favor llame al 1-800-338-8366. Si vive en el área de Des Moines, puede Lamar al 515-256-4606. Importante: Asegúrese de firmar con su nombre en la página 3. Por favor, uso tinta azul o negro. Envíe por correo antes de Recibirá una carta en la que se le informa si su cobertura de IowaCare fue renovada.

Infórmenos sobre usted Nombre

Número telefónico

Dirección postal

Dirección de correspondencia (si es diferente)

Ciudad

Estado

Código postal

Personas en su hogar Liste todas las personas en su hogar, incluyéndose usted, y marque sí o no si está solicitando para esa persona. Por favor utilice otra hoja de papel si lo necesita. ¿Solicita? Sí / No

Nombre (nombre, apellido)

Sexo M/F

Relación con usted

Fecha de nacimiento

Número de Seguridad Social

Raza opcional

Ciudadano Sí / No

Si es extranjero, estatus

Usted

Liste cualquier persona de su hogar que sea discapacitado: Liste cualquier persona de su hogar que esté embarazada: Fecha posible de parto Si tiene facturas médicas sin pagar, incluya una copia de las que aún deba. ¿Tiene usted alguna forma de facturas sin pagar el último mes?  Sí  No En caso afirmativo, anote en la que debe facturas

470-4364(S) (Rev. 2/12) S4364A

Página 1

Ingreso Usted debe indicarnos todo el dinero que las personas en su hogar reciben o esperan recibir. Si deja un espacio en blanco, significa que usted no recibe ese dinero. Si es autónomo, dar a su beneficio neto anual, que es el ingreso bruto menos el costo de gastos de negocios, excepto la depreciación y los gastos de capital. Si está temporalmente sin trabajo, estime su ingreso anual. Utilice otra hoja de papel si lo necesita. ¿Quién es su empleador? De dónde proviene el dinero

Quién obtiene el dinero

Cantidad

Mensual o anual

Dinero del trabajo sin incluir impuestos (bruto) Trabajador independiente o trabajos ocasionales (ingreso anual) Propinas Desempleo o compensación del trabajador (bruto) Seguridad Social o SSI (bruto) Beneficios de veteranos, pensiones o jubilación Mantenimiento infantil o pensión de alimentos Dinero de amigos o parientes Otros:

Recursos o Activos Un recurso es efectivo o cualquier cosa que pueda ser cambiada a efectivo. Liste todos sus recursos y el monto o valor. Incluye elementos como dinero en efectivo disponible, cuentas corrientes, vehículos, seguros de vida, títulos valores, bonos, certificados de depósitos (CDs), fondos fiduciarios, cuentas de jubilación, contratos de entierro y espacios de entierro. Si deja un espacio en blanco, entenderemos que significa que no tiene recursos. Personas con recurso

Tipo de recurso

Monto o valor

Ubicación del recurso

Seguro de salud Debe responder sí o no a las siguientes preguntas. ¿Alguien tiene Medicare?

Sí

No

¿Quién?

¿Alguien tiene otro seguro de salud?

Sí

No

¿Quién?

¿Su empleador ofrece seguro de salud?

Sí

No

¿Quién?

Si tiene hijos, ¿sus hijos tienen Healthy and Well Kids en Iowa (hawk-i)? ¿Cuánto cuesta su prima mensual?

470-4364(S) (Rev. 2/12) S4364B

$10

$20

Página 2

Sí

$15 (sólo dental)

No

Información de Seguridad social Debo suministrar los números de seguridad social para todo aquel que desee IowaCare. Esto lo requiere la sección 1137(a)(1) de la Ley de Seguridad Social y 42 CFR 435.910. Nosotros usamos los números de seguridad social para:

• • •

Verificar ingresos, elegibilidad y pagos de IowaCare

•

Cruzar registros con otras agencias.

Determinar el derecho de una persona a IowaCare Cumplir con la ley federal

Su firma y entendimiento Certifico, bajo la gravedad del juramento, que:

•

Las respuestas que di son correctas y completas según mi leal saber y entender.

•

Mi respuesta sobre el estado de ciudadanía o extranjería de cada persona que hace la solicitud es acertada.

Entiendo que si soy aprobado para IowaCare, es possible que deba pagar una prima mensual o pedir penuria a fin de obtener cobertura. También entiendo que:

•

Se me enviará un extracto de cobro para cada mes que deba la prima.

•

Acepto entregar a la agencia Medicaid los pagos de gastos médicos realizados por terceros para mí y otras personas elegibles para Medicaid, para las cuales yo estoy legalmente autorizada a asignar beneficios. Además, acepto cooperar para obtener pagos de gastos médicos provenientes de terceros.

•

Si aún no estoy en IowaCare y debo una prima, las primas no vencerán hasta el mes siguiente a que se tome una decisión sobre mi solicitud. Si esta es una solicitud para continuar IowaCare y si debo pagar una prima, ésta se pagará cada mes del nuevo período de inscripción.

•

Debo devolver el extracto de cobro con mi pago o solicitar el estado de penuria económica cada mes aún si no recibo atención médica en esos meses. El extracto de cobro no debe tener matasellos anterior a la fecha límite de pago allí marcada.

•

Si debo una prima, me comprometo a pagarla o a pedir estado de penuria por un mínimo por cuatro meses, aún si IowaCare se suspende antes del final de estos cuatro meses.

•

Si no pago mi prima ni solicito el estado de penuria económica antes de la fecha límite de pago, se suspenderá mis beneficios de IowaCare.

•

Si no pago mi prima ni solicito el estado de penuria económica antes de la fecha límite de pago, deberé al DHS el monto no pagado. Este monto no pagado se constituirá en una deuda legal que el DHS puede cobrar por cualquier medio permitido por la ley.

Su firma o marca de un miembor de IowaCare

Fecha de hoy

Firma o marque de un miembor de IowaCare segundo, si es aplicable

Fecha de hoy

Firma de la persona que ayudó a llenar el formulario, se la hay

Fecha de hoy

470-4364(S) (Rev. 2/12) S4364C

Página 3

Utilice esta hoja para listar ingresos no mostrados en la sección de Ingreso y cualquier comentario.

470-4364(S) (Rev. 2/12) S4364D

Página 4

Guarde esta parte para su archivo ¿Cuánto costará? Es posible que deba pagar una prima para obtener IowaCare. El monte de su prima se base en la cantidad de dinero que recibe cada mes. Si debe pagar prima, ésta se vence al final de cada mes. Usted será responsable del pago de por lo menos cuatro meses de primas.

La cobertura de IowaCare puede parar si no paga su prima mensual ni solicita estado de penuria.

Montos de primas Algunos miembros de IowaCare deben pagar una prima para recibir IowaCare. Para averiguar si usted tiene que pagar una prima, sume los ingresos de todos los miembros del grupo familiar que viven en su hogar. Mire el siguiente cuadro Family Size (Tamaño de la Familia). Si sus ingresos familiares son superiores a los ingresos establecidos para el tamaño de la familia, entonces tendrá que pagar una prima. Tamaño de la familia 150% del FPL (nivel federal de pobreza)= Ingreso mensual de

1

2

3

4

5

6

$1,397

$1,892

$2,387

$2,882

$3,377

$3,872

Si usted es el único miembro de su familia que desea recibir IowaCare, las primas figuran en la columna One IowaCare Member (Un miembro de IowaCare). Si los que quieren recibir IowaCare son dos o más integrantes del grupo familiar, las primas conjuntas figuran en la columna Two or More Members (Dos o más miembros). Primas conjuntas significa que los miembros de IowaCare de un grupo familiar pagan solamente una prima para todos. Premium Gráfico Un miembro de IowaCare y el ingreso es igual o inferior a un FPL de:

El importe de la prima del miembro es:

Dos o más y el ingreso del grupo familiar es igual o inferior a un FPL de:

La prima conjunta de los miembros es:

150% = $1,397

No Cost

150% = $1,892

No Cost

160% = $1,490

$51.00

160% = $2,018

$69.00

170% = $1,583

$55.00

170% = $2,144

$73.00

180% = $1,676

$58.00

180% = $2,270

$78.00

190% = $1,769

$61.00

190% = $2,396

$82.00

200% = $1,862

$65.00

200% = $2,522

$86.00

Información sobre su estado de inmigración Usted puede hacer la solicitud para parte de su hogar, aún si algunos miembros no tienen un estado legal de inmigrante. Es posible que deba presentar prueba de su estado de inmigración para personas que no son ciudadanos o nacionales de los EE.UU. El estado de extranjería de su hogar puede ser verificado a través del Citizenship and Immigration Service. Cualquier información que recibamos del Citizen and Immigration Service puede afectar lo que su hogar pueda obtener. No contactaremos al Citizen and Immigration Service para averiguar sobre personas para las cuales no haga una solicitud. Sin embargo, podemos utilizar sus ingresos y recursos para verificar si el resto del hogar puede ayudar. 470-4364(S) (Rev. 2/12) S4364E

Página 5

Guarde esta parte para su archivo Cambios al informe Informe los cambios al DHS dentro de los 10 días calendario siguientes a la fecha en que ocurra el cambio. Esto incluye cambios en:

•

Dirección postal

•

Cobertura del seguro de salud

•

Mudarse fuera de Iowa

•

Ingresar a una institución no médica

No necesita informar lo siguiente:

•

Cambios en su ingreso

•

Alguien que se entre a vivir o salga de su hogar

•

Cambios en recursos o activos

Usted tiene derecho a apelar Usted o la persona que le esté ayudando, puede solicitar una audiencia de apelación en caso que usted no esté de acuerdo con alguna acción tomada en su caso. Debe apelar por escrito. Para apelar por escrito, haga una de las siguientes cosas:

• • •

Llene una apelación electrónicamente en https://dhssecure.dhs.state.ia.us/forms, ó Escriba una carta en la que nos diga por qué cree que la decisión está errada, o Llene un formulario de Apelación y Solicitud de Audiencia, que puede obtener de la oficina del DHS de su condado.

Envíe o lleve su apelación al Department of Human Services, Appeals Section, 5th Floor, 1305 E Walnut Street, Des Moines, Iowa 50319-0114. Si necesita ayuda para llenar una apelación, solicítela en la oficina del DHS local. Usted puede representarse a sí mismo(a). O puede hacer que un amigo, pariente, abogado o alguien más actúe en su nombre. Puede contactar su oficina local del DHS para obtener servicios legales. Es posible que deba pagar por estos servicios legales. Si lo hace, su pago se basará en su ingreso. También puede llamar a Iowa Legal Aid al (800) 532-1275. Si vive en Polk County, llame al (515) 243-1193.

No será discriminado(a) Politica Relativa a la Discriminación, el Acoso, la Acción Afirmativa, y la Oportunidad Igualitaria de Empleo Es política del Iowa Department of Human Services ofrecer trato igualitario en cuanto a empleo y ofrecimiento de servicios a los solicitantes, empleados y clientes, sin importar su raza, color, nacionalidad, sexo, orientación de sexual, identidad de género, religión, edad, incapacidad, creencia política o estatus de veterano. Si cree que DHS le ha discriminado a acosado, le agradeceremos que envíe una carta explicando detalladamente su queja a: Iowa Department of Human Services, Office of Human Resources, Hoover Building – 1st Floor, 1305 E. Walnut, Des Moines, IA 50319-0114; fax (515) 281-4243, o a tráves de correo electronic a [email protected] 470-4364(S) (Rev. 2/12) S4364F

Página 6

Iowa Department of Human Services Iowa Department of Human Services

IowaCare Renewal Application

County Number:

Worker Name:

Case Number:

Phone No.

It’s time for the yearly renewal of your IowaCare coverage. In order to renew your IowaCare, you need to answer all of the questions on the application below. If you have any questions or need help filling out this form, please call 1-800-338-8366. If you live in the Des Moines area, you can call 515-256-4606. Important: Please make sure to sign your name on page 3. Please use only blue or black ink. Mail the application before You will get a letter letting you know if your IowaCare coverage is renewed.

Tell Us About You Name

Telephone Number

Street Address

Mailing Address (if different)

City

State

Zip Code

People in Your Home List all the people in your home, including yourself, and mark yes or no if you are applying for that person. Please use another piece of paper, if needed. Apply for? Yes/No

Name (First, Last)

Sex M/F

Relationship to You

Birth Date

Social Security Number

Race Optional

Self

List anyone in your home who is disabled: List anyone in your home who is pregnant: Due Date If you have unpaid medical bills, please include a copy of the bills you still owe. Do you have any unpaid bills from last month?

Yes

If yes, write down where you owe the bills. 470-4364(M) (Rev. 2/12)

Page 1

No

Citizen Yes/No

If Alien, Status

Income You must tell us all of the money the people in your household get or expect to get. If you leave a space blank, that means you don’t get that money. If self-employed, give your annual net profit, which is gross income minus the cost of business expense except depreciation and capital expenses. If off work temporarily, estimate your annual income. Use another piece of paper, if needed. Who is your employer? Where the Money Comes From

Who Gets the Money

Amount

Monthly or Yearly

Money from Work Before Taxes (Gross) Self-Employment or Odd Jobs (Annual income) Tips Unemployment or Worker’s Comp (Gross) Social Security or SSI (Gross) Veterans Benefits, Pensions or Retirement Child Support or Alimony Money from Friends or Relatives Other (including lump sum):

Resources or Assets A resource or asset is cash or anything that can be changed to cash. List all of your resources or assets and the amount or value. This includes items like cash on hand, checking accounts, vehicles, life insurance, stocks, bonds, certificates of deposits (CDs), trust funds, retirement accounts, burial contracts, and burial spaces. If you leave a space blank, we will take that to mean that you have no resources or assets. Person with Resource

Type of Resource

Amount or Value

Location of Resource

Health Insurance You must answer yes or no to the following questions. Does anyone have Medicare?

Yes

No Who?

Does anyone have other health insurance?

Yes

No Who?

Does your employer offer health insurance?

Yes

No Who?

If you have kids, are they covered by the Healthy and Well Kids in Iowa (hawk-i) program?

Yes

No

If yes, how much is your hawk-i premium?

$10

$20

470-4364(M) (Rev. 2/12)

Page 2

$15 (dental only)

Social Security Information I must give the social security numbers for everyone who wants IowaCare. This is required by Section 1137(a)(1) of the Social Security Act and 42 CFR 435.910. We use social security numbers to:

•

Check income, eligibility, and IowaCare payments.

•

Determine a person’s right to IowaCare.

•

Comply with federal law.

•

Match records with other agencies.

Your Signature and Understanding I certify, under penalty of perjury, that:

•

The answers I gave are correct and complete to the best of my knowledge.

•

My answer about citizenship or alien status of each person applying for assistance is correct.

I understand that if I am approved for IowaCare, I may have to pay a monthly premium or claim hardship in order to get coverage. I also understand:

•

I will be sent a billing statement for each month that I owe a premium.

•

I agree to assign medical payments from a third party to the Medicaid agency for myself and others who are eligible for Medicaid for whom I legally can assign benefits. I also agree to cooperate in obtaining medical payments from third parties.

•

If I am not already on IowaCare and I owe a premium, premiums will not be due until the month after a decision is made on my application. If this is an application to continue IowaCare and if I owe a premium, a premium will be due for each month of the new enrollment period.

•

I must return the billing statement with my payment or claim hardship each month, even if I do not get medical care in those months. This statement must be postmarked no later than the due date on the billing statement.

•

If I owe a premium, I agree to either pay the premium or claim hardship for a minimum of four months, even if IowaCare stops before the end of these four months.

•

If I do not pay my premium or claim hardship by the due date on the billing statement, my IowaCare benefits will stop.

•

If I do not pay my premium or claim hardship by the due date, I will owe DHS any unpaid amount. This unpaid amount will become a legal debt that DHS may collect by any means allowed by law.

Signature or Mark of IowaCare Member

Today’s Date

Signature or Mark of Second IowaCare Member (if applies)

Today’s Date

Signature of Person, If Any, Who Helped Complete the Form

Today’s Date

470-4364(M) (Rev. 2/12)

Page 3

Use this sheet to list income not shown in the Income section and any comments.

470-4364(M) (Rev. 2/12)

Page 4

Keep this part for your records How Much Will It Cost? You may need to pay a premium to get IowaCare. The amount of your premium is based on the amount of money you get each month. If you owe a premium, it is due at the end of each month. You will be responsible for at least four months of premiums. IowaCare coverage may stop if you don’t pay your monthly premium or claim hardship.

Premium Amounts You may have to pay a premium to get IowaCare. To find out if you will have to pay a premium, add the income from all the family members in your home. Look at the family size chart below. If your family income is above the amount for the family size, then you will have to pay a premium. Family Size 150 % of FPL = Monthly income of

1

2

3

4

5

6

$1,397

$1,892

$2,387

$2,882

$3,377

$3,872

If you are the only one in the household who wants IowaCare, the premiums are shown in the One IowaCare Member column. If there are two or more people in your household who want IowaCare, the joint premiums are shown in the Two or More Members column. Joint premiums mean that all the IowaCare members in one household pay only one premium together. Premium Chart One IowaCare member and income is at or below the FPL of:

Member’s premium amount is:

Two or more members and income is at or below the FPL of:

Member’s joint premium amount is:

150% = $1,397 160% = $1,490

No cost $51

150% = $1,892 160% = $2,018

No cost $69

170% = $1,583

$55

170% = $2,144

$73

180% = $1,676

$58

180% = $2,270

$78

190% = $1,769 200% = $1,862

$61 $65

190% = $2,396 200% = $2,522

$82 $86

Information on Immigration Status You can apply for part of your household even if some members do not have legal immigrant status. You may need to give proof of immigration status for the people who are not U.S. citizens or nationals. Your household’s alien status may be checked through the Citizenship and Immigration Service. Any information we get from the Citizenship and Immigration Service may affect what your household may get. We will not contact the Citizenship and Immigration Service about the people you don’t apply for. However, we may use their income and resources to see if the rest of the household can get help.

470-4364(M) (Rev. 2/12)

Page 5

Keep this part for your records Changes to Report Report changes to DHS within 10 calendar days from the date the change happens. This includes changes in:

• • • •

Mailing address Health insurance coverage Moving out of Iowa Entering a non-medical institution

You do not need to report the following:

• • •

Changes in your income Someone moves in or out of your home Changes in resources or assets

You Have the Right to Appeal You, or the person helping you, may request an appeal hearing if you do not agree with any action taken on your case. You must appeal in writing. To appeal in writing, do one of the following:

• • •

Fill out an appeal electronically at https://dhssecure.dhs.state.ia.us/forms/, or Write a letter telling us why you think a decision is wrong, or Fill out an Appeal and Request for Hearing form, which you can get from your county DHS office.

Send or take your appeal to the Department of Human Services, Appeals Section, 5th Floor, 1305 E Walnut Street, Des Moines, Iowa 50319-0114. If you need help filing an appeal, ask your local DHS office. You can represent yourself. Or, you can have a friend, relative, lawyer or someone else act on your behalf. You may contact your local DHS office about legal services. You may have to pay for these legal services. If you do, your payment will be based on your income. You may also call Iowa Legal Aid at (800) 532-1275. If you live in Polk County, call (515) 243-1193.

You Will Not Be Discriminated Against Policy Regarding Discrimination, Harassment, Affirmative Action and Equal Employment Opportunity It is the policy of the Iowa Department of Human Services (DHS) to provide equal treatment in employment and provision of services to applicants, employees and clients without regard to race, color, national origin, sex, sexual orientation, gender identity, religion, age, disability, political belief or veteran status. If you feel DHS has discriminated against or harassed you, please send a letter detailing your complaint to: Iowa Department of Human Services, Office of Human Resources, Hoover Building – 1st Floor, 1305 E Walnut, Des Moines, IA 50319-0114; fax (515) 281-4243 or via e-mail [email protected]

470-4364(M) (Rev. 2/12)

Page 6

Iowa Department of Human Services Iowa Department of Human Services

IowaCare Renewal Application (Solicitud Renovación de IowaCare)

Número del condado:

Nombre del trabajador:

Número de caso:

Teléfono

Es hora de la renovación anual de su cobertura de IowaCare. A fin de renovar su IowaCare, debe responder todas las preguntas de la solicitud que se encuentra a continuación. Si tiene preguntas o necesita ayuda para llenar este formulario, por favor llame al 1-800-338-8366. Si vive en el área de Des Moines, puede Lamar al 515-256-4606. Importante: Asegúrese de firmar con su nombre en la página 3. Por favor, uso tinta azul o negro. Envíe por correo antes de Recibirá una carta en la que se le informa si su cobertura de IowaCare fue renovada.

Infórmenos sobre usted Nombre

Número telefónico

Dirección postal

Dirección de correspondencia (si es diferente)

Ciudad

Estado

Código postal

Personas en su hogar Liste todas las personas en su hogar, incluyéndose usted, y marque sí o no si está solicitando para esa persona. Por favor utilice otra hoja de papel si lo necesita. ¿Solicita? Sí / No

Nombre (nombre, apellido)

Sexo M/F

Relación con usted

Fecha de nacimiento

Número de Seguridad Social

Raza opcional

Ciudadano Sí / No

Si es extranjero, estatus

Usted

Liste cualquier persona de su hogar que sea discapacitado: Liste cualquier persona de su hogar que esté embarazada: Fecha posible de parto Si tiene facturas médicas sin pagar, incluya una copia de las que aún deba. ¿Tiene usted alguna forma de facturas sin pagar el último mes? En caso afirmativo, anote en la que debe facturas 470-4364(MS) (Rev. 2/12)

Página 1

Sí

No

Ingreso Usted debe indicarnos todo el dinero que las personas en su hogar reciben o esperan recibir. Si deja un espacio en blanco, significa que usted no recibe ese dinero. Si es autónomo, dar a su beneficio neto anual, que es el ingreso bruto menos el costo de gastos de negocios, excepto la depreciación y los gastos de capital. Si está temporalmente sin trabajo, estime su ingreso anual. Utilice otra hoja de papel si lo necesita. ¿Quién es su empleador? De dónde proviene el dinero

Quién obtiene el dinero

Cantidad

Mensual o anual

Dinero del trabajo sin incluir impuestos (bruto) Trabajador independiente o trabajos ocasionales (ingreso anual) Propinas Desempleo o compensación del trabajador (bruto) Seguridad Social o SSI (bruto) Beneficios de veteranos, pensiones o jubilación Mantenimiento infantil o pensión de alimentos Dinero de amigos o parientes Otros:

Recursos o Activos Un recurso es efectivo o cualquier cosa que pueda ser cambiada a efectivo. Liste todos sus recursos y el monto o valor. Incluye elementos como dinero en efectivo disponible, cuentas corrientes, vehículos, seguros de vida, títulos valores, bonos, certificados de depósitos (CDs), fondos fiduciarios, cuentas de jubilación, contratos de entierro y espacios de entierro. Si deja un espacio en blanco, entenderemos que significa que no tiene recursos. Personas con recurso

Tipo de recurso

Monto o valor

Ubicación del recurso

Seguro de salud Debe responder sí o no a las siguientes preguntas. ¿Alguien tiene Medicare?

Sí

No

¿Quién?

¿Alguien tiene otro seguro de salud?

Sí

No

¿Quién?

¿Su empleador ofrece seguro de salud?

Sí

No

¿Quién?

Si tiene hijos, ¿sus hijos tienen Healthy and Well Kids en Iowa (hawk-i)? ¿Cuánto cuesta su prima mensual?

$10

470-4364(MS) (Rev. 2/12)

Página 2

$20

Sí

$15 (sólo dental)

No

Información de Seguridad social Debo suministrar los números de seguridad social para todo aquel que desee IowaCare. Esto lo requiere la sección 1137(a)(1) de la Ley de Seguridad Social y 42 CFR 435.910. Nosotros usamos los números de seguridad social para:

• • • •

Verificar ingresos, elegibilidad y pagos de IowaCare Determinar el derecho de una persona a IowaCare Cumplir con la ley federal Cruzar registros con otras agencias.

Su firma y entendimiento Certifico, bajo la gravedad del juramento, que:

• •

Las respuestas que di son correctas y completas según mi leal saber y entender. Mi respuesta sobre el estado de ciudadanía o extranjería de cada persona que hace la solicitud es acertada.

Entiendo que si soy aprobado para IowaCare, es possible que deba pagar una prima mensual o pedir penuria a fin de obtener cobertura. También entiendo que:

•

Se me enviará un extracto de cobro para cada mes que deba la prima.

•

Acepto entregar a la agencia Medicaid los pagos de gastos médicos realizados por terceros para mí y otras personas elegibles para Medicaid, para las cuales yo estoy legalmente autorizada a asignar beneficios. Además, acepto cooperar para obtener pagos de gastos médicos provenientes de terceros.

•

Si aún no estoy en IowaCare y debo una prima, las primas no vencerán hasta el mes siguiente a que se tome una decisión sobre mi solicitud. Si esta es una solicitud para continuar IowaCare y si debo pagar una prima, ésta se pagará cada mes del nuevo período de inscripción.

•

Debo devolver el extracto de cobro con mi pago o solicitar el estado de penuria económica cada mes aún si no recibo atención médica en esos meses. El extracto de cobro no debe tener matasellos anterior a la fecha límite de pago allí marcada.

•

Si debo una prima, me comprometo a pagarla o a pedir estado de penuria por un mínimo por cuatro meses, aún si IowaCare se suspende antes del final de estos cuatro meses.

•

Si no pago mi prima ni solicito el estado de penuria económica antes de la fecha límite de pago, se suspenderán mis beneficios de IowaCare.

•

Si no pago mi prima ni solicito el estado de penuria económica antes de la fecha límite de pago, deberé al DHS el monto no pagado. Este monto no pagado se constituirá en una deuda legal que el DHS puede cobrar por cualquier medio permitido por la ley.

Su firma o marca de un miembor de IowaCare

Fecha de hoy

Firma o marque de un miembor de IowaCare segundo, si es aplicable

Fecha de hoy

Firma de la persona que ayudó a llenar el formulario, se la hay

Fecha de hoy

470-4364(MS) (Rev. 2/12)

Página 3

Utilice esta hoja para listar ingresos no mostrados en la sección de Ingreso y cualquier comentario.

470-4364(MS) (Rev. 2/12)

Página 4

Guarde esta parte para su archivo ¿Cuánto costará? Es posible que deba pagar una prima para obtener IowaCare. El monto de su prima se basa en la cantidad de dinero que reciba cada mes. Si debe pagar prima, ésta se vence al final de cada mes. Usted será responsable del pago de por lo menos cuatro meses de primas. La cobertura de IowaCare puede parar si no paga su prima mensual ni solicita estado de penuria.

Montos de primas Algunos miembros de IowaCare deben pagar una prima para recibir IowaCare. Para averiguar si usted tiene que pagar una prima, sume los ingresos de todos los miembros del grupo familiar que viven en su hogar. Mire el siguiente cuadro Family Size (Tamaño de la Familia). Si sus ingresos familiares son superiores a los ingresos establecidos para el tamaño de la familia, entonces tendrá que pagar una prima.

Tamaño de la familia 150% del FPL (nivel federal de pobreza) = Ingreso mensual de

1

2

3

4

5

6

$1,397

$1,892

$2,387

$2,882

$3,377

$3,872

Si usted es el único miembro de su familia que desea recibir IowaCare, las primas figuran en la columna One IowaCare Member (Un miembro de IowaCare). Si los que quieren recibir IowaCare son dos o más integrantes del grupo familiar, las primas conjuntas figuran en la columna Two or More Members (Dos o más miembros). Primas conjuntas significa que los miembros de IowaCare de un grupo familiar pagan solamente una prima para todos.

Premium Gráfico Un miembro de IowaCare y el ingreso es igual o inferior a un FPL de:

El importe de la prima del miembro es:

Dos o más y el ingreso del grupo familiar es igual o inferior a un FPL de:

La prima conjunta de los miembros es:

150% = $1,397

No cost

150% = $1,892

No cost

160% = $1,490

$51

160% = $2,018

$69

170% = $1,583

$55

170% = $2,144

$73

180% = $1,676

$58

180% = $2,270

$78

190% = $1,769

$61

190% = $2,396

$82

200% = $1,862

$65

200% = $2,522

$86

Información sobre su estado de inmigración Usted puede hacer la solicitud para parte de su hogar, aún si algunos miembros no tienen un estado legal de inmigrante. Es posible que deba presentar prueba de su estado de inmigración para personas que no son ciudadanos o nacionales de los EE.UU. El estado de extranjería de su hogar puede ser verificado a través del Citizenship and Immigration Service. Cualquier información que recibamos del Citizen and Immigration Service puede afectar lo que su hogar pueda obtener. No contactaremos al Citizen and Immigration Service para averiguar sobre personas para las cuales no haga una solicitud. Sin embargo, podemos utilizar sus ingresos y recursos para verificar si el resto del hogar puede ayudar. 470-4364(MS) (Rev. 2/12)

Página 5

Guarde esta parte para su archivo Cambios al informe Informe los cambios al DHS dentro de los 10 días calendario siguientes a la fecha en que ocurra el cambio. Esto incluye cambios en:

• • • •

Dirección postal: Cobertura del seguro de salud Mudarse fuera de Iowa Ingresar a una institución no médica

No necesita informar lo siguiente:

• Cambios en su ingreso • Alguien que se entre a vivir o salga de su hogar • Cambios en recursos o activos

Usted tiene derecho a apelar Usted o la persona que le esté ayudando, puede solicitar una audiencia de apelación en caso que usted no esté de acuerdo con alguna acción tomada en su caso. Debe apelar por escrito. Para apelar por escrito, haga una de las siguientes cosas:

• • •

Llene una apelación electrónicamente en https://dhssecure.dhs.state.ia.us/forms, ó Escriba una carta en la que nos diga por qué cree que la decisión está errada, o Llene un formulario de Apelación y Solicitud de Audiencia, que puede obtener de la oficina del DHS de su condado.

Envíe o lleve su apelación al Department of Human Services, Appeals Section, 5th Floor, 1305 E Walnut Street, Des Moines, Iowa 50319-0114. Si necesita ayuda para llenar una apelación, solicítela en la oficina del DHS local. Usted puede representarse a sí mismo(a). O puede hacer que un amigo, pariente, abogado o alguien más actúe en su nombre. Puede contactar su oficina local del DHS para obtener servicios legales. Es posible que deba pagar por estos servicios legales. Si lo hace, su pago se basará en su ingreso. También puede llamar a Iowa Legal Aid al (800) 532-1275. Si vive en Polk County, llame al (515) 243-1193.

No será discriminado(a) Política Relativa a la Discriminación, el Acoso, la Acción Afirmativa, y la Oportunidad Igualitaria de Empleo Es política del Iowa Department of Human Services ofrecer trato igualitario en cuanto a empleo y ofrecimiento de servicios a los solicitantes, empleados y clientes, sin importar su raza, color, nacionalidad, sexo, orientación de sexual, identidad de género, religión, edad, incapacidad, creencia política o estatus de veterano. Si cree que DHS le ha discriminado o acosado, le agradeceremos que envíe una carta explicando detalladamente su queja a: Iowa Department of Human Services, Office of Human Resources, Hoover Building – 1st Floor, 1305 E. Walnut, Des Moines, IA 50319-0114; fax (515) 281-4243, o a través de correo electrónico a [email protected]

470-4364(MS) (Rev. 2/12)

Página 6

Iowa Department of Human Services

MAC Income Worksheet Case Name:

Case Number:

Application Month:

Benefit Month:

I.

RESPONSIBLE PERSON INCOME (stepparent, self-supporting parents, etc.) EMPLOYEE:

EARNED INCOME Date Paid

Gross

Total

$

$

$

20% earned income deduction

-

$

$

$

Child care expenses

-

$

$

$

+

$

$

$

Unearned income Child support, alimony or other payments to people outside the home

$

$

$

RP/dependent diversion

-

$

$

$ $

A. Responsible Person Income

-

=

$

EARNED INCOME

EMPLOYEE:

EMPLOYER:

Date Paid

Gross

EMPLOYEE:

Tips

Total

EMPLOYER:

Date Paid

Gross

Tips

Total

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

Total gross earnings

=

20% earned income deduction Adult/child care expenses Court-ordered child support paid to people outside the home

B. Countable Earned Income III.

EMPLOYER:

Tips

Total gross earnings

II.

Date:

$

Total gross earnings

=

-

20% earned income deduction

-

-

Adult/child care expenses Court-ordered child support paid to people outside the home

-

=

$

$

=

C. Countable Earned Income

$

UNEARNED INCOME Court-ordered child support paid to persons outside the home (any remaining amount)

$

Unearned income of children Unearned income of parent

+

Child support: $ minus exemption

+

D. Total Unearned Income

E. Total Countable Income Subtotal (Total of boxes A through D)

470-2527 (Rev. 4/12)

Copy 1 - Case record

=

$ Copy 2 - Client

-

=

$

E. Total countable income from previous page:

$

Household size:

Check the box for the applicable period: Poverty Levels After April 1, 2012 Maximum income limit at 133% of poverty (If income does not exceed this amount, children age 1 through age 18 are eligible.)

$

Maximum income limit at 300% of poverty (If income does not exceed this amount, pregnant women and infants under age one are eligible.)

$

Note: Consider an unborn child in determining the size of the household. Do not consider the stepparent in determining the size of the household if the stepparent is not included in the eligible group. Poverty Levels Before April 1, 2012 Maximum income limit at 133% of poverty (If income does not exceed this amount, children age 1 through age 18 are eligible.)

$

Maximum income limit at 300% of poverty (If income does not exceed this amount, pregnant women and infants under age one are eligible.)

$

Note: Consider an unborn child in determining the size of the household. Do not consider the stepparent in determining the size of the household if the stepparent is not included in the eligible group. Notes:

470-2527 (Rev. 4/12)

Iowa Department of Human Services

Noncooperation Notice FILE THIS NOTICE IN A PERMANENT PLACE IN THE CASE RECORD County:

Date:

Case Worker:

QC Reviewer:

Case Name:

Phone:

Persons Not Cooperating:

Case No: QC Review No:

Client cooperation with Quality Control is an eligibility requirement per manual reference . The above named client has failed to cooperate with Quality Control. Please take action as directed in the boxes selected below: The client is currently receiving assistance. Send a Notice of Decision canceling program benefits for . The client is not currently receiving assistance. File this notice in the case file. Benefits to be sanctioned: FIP/Medicaid Should the client reapply before , the client must cooperate with Quality Control as an eligibility requirement, i.e., the client is ineligible until the agency has been notified by the Quality Control reviewer that the client has cooperated. After the above given date, an actual Quality Control review will not be completed; however, to meet program requirements the client must be willing to cooperate with Quality Control. This determination should be made by the local agency worker. Food Assistance Should the client reapply before , the client must cooperate with Quality Control as an eligibility requirement, i.e., the client is ineligible until the agency has been notified by the Quality Control reviewer that the client has cooperated. If the noncooperating person moves to a different household, the ineligibility follows that person to the new household. After the above given date, the household shall not be determined ineligible for its refusal to cooperate with Quality Control, but the household must provide the agency with verification of all eligibility requirements before being determined eligible.

470-0479 (Rev. 3/12)

Title 6: Income Maintenance Programs Appendix April 6, 2012

Page 214a Noncooperation Notice 470-0479

Noncooperation Notice, Form 470-0479 Purpose

The Bureau of Quality Control uses the Noncooperation Notice to notify the local office when a client has refused to cooperate and to instruct the local office on the action to take on a client’s case.

Source

An electronic template for form 470-0479 is available on the QC share. Reviewers need to copy the form to their computer.

Completion

The Quality Control reviewer completes this form whenever Quality Control determines that a client has refused to cooperate.

Distribution

The Quality Control reviewer sends the original to the local office and files a copy as a permanent record with the completed review.

Data

The Quality Control reviewer completes the following: ♦ Date: The date the form is prepared. ♦ County: The local office where the client currently receives benefits, last received benefits, or had an application rejected. ♦ QC Reviewer: The Quality Control reviewer’s name. ♦ Case Worker: The IM worker who is currently handling the case record or last handled the case record. ♦ Phone: The Quality Control reviewer’s telephone number. ♦ Case Name: The client’s name. ♦ Case No: The client’s case number. ♦ Persons Not Cooperating: The name of the person who was required to cooperate with Quality Control but failed to. List the client’s name here if it is not the same person as the case name. All noncooperating household members should be listed on this form. ♦ QC Review No: The client’s Quality Control review number. ♦ Reference: The manual reference for failure to cooperate.

Iowa Department of Human Services Employees’ Manual

Title 6: Income Maintenance Programs Appendix Revised April 6, 2012

Page 215 Noncooperation Notice 470-0479

♦ First Check Box: An indication whether the noncooperating client is in active status and the name of the program to be canceled. ♦ Second Check Box: Instruction for cases on which the client is not currently receiving assistance. ♦ Third and Fourth Check Boxes: If active, the name of the assistance program for which Quality Control determined the client refused to cooperate and the length of the sanction period.

Iowa Department of Human Services Employees’ Manual

Iowa Department of Human Services Terry E. Branstad Governor

Kim Reynolds Lt. Governor

Charles M. Palmer Director

Dear Your Medical Assistance has been canceled. You may be eligible for Medical Assistance under one of the following programs: The Medically Needy Program You will need to pay a spenddown (like a deductible), of $______ for the months of _________________, before you will be eligible for Medicaid. If you think your future medical bills will exceed $_____ for the months of _________________, or if you already have more than $_____ in unpaid medical bills, then the Medically Needy program may help you. If your medical bills are less than or expected to be less than $______ for the months of _________________, you may receive benefits from the IowaCare program listed below. The IowaCare Program This program offers limited medical services. Services will be provided at ____________________________________. OR The IowaCare Program This program offers limited medical services. Services will be provided at ____________________________________. You will need to pay a monthly premium to receive IowaCare services. If you wish to receive IowaCare medical assistance, please sign the enclosed IowaCare Premium Agreement form and return it by __________________. The Iowa Family Planning Network (IFPN) This program offers limited family planning services (example: annual exams, lab tests, most contraceptive supplies, and some STD treatment). This program is available to persons ages 12 through 54. If you had a pregnancy end within the last 12 months and were on Medicaid, you are automatically eligible for this program. Medicaid for Employed People with Disabilities (MEPD) This program offers Medicaid for disabled persons under the age of 65 who have income from employment or being self-employed. If you would like to be considered for any of these medical programs, please contact me no later than 4:30 p.m. on __________________. If you don’t, your medical coverage will end, and I will not be able to determine if you are eligible for Medical Assistance under another program. Sincerely,

Enclosures:

Medicaid for the Medically Needy, Comm. 30 IowaCare Premium Agreement, 470-4194 It's Your Future, Comm. 249 MEPD Brochure, Comm. 180

470-4832 (Rev. 3/12) W4832A

Iowa Department of Human Services

Refugee Referral to IWD and to Refugee Services APPLICANT: You are instructed to report in person and present this form to the Iowa Workforce Development Office at . You must register for employment. After Iowa Workforce Development has signed this form, you must register with the Bureau of Refugee Services by sending this form to the address shown below. The Bureau of Refugee Services will sign and return this form to your income maintenance worker. Your worker cannot determine your eligibility for assistance without this form. If you have any questions, call the Bureau of Refugee Services at 1-800-362-2780 or 283-7999 if calling locally in Des Moines. TO: Iowa Workforce Development THIS WILL INTRODUCE: Name Address Social Security Number

Case Number

IM Worker’s Name

Date

Office Address

Iowa Workforce Development Signature

Date

Bureau of Refugee Services Signature

Date

Original – IM file

Copy 1 – Refugee Services

470-0480 (Rev. 3/12)

Mail to: Bureau of Refugee Services 401 SW 7th Street Ste N Des Moines IA 50309

Copy 2 – Control

Title 6: Income Maintenance Programs Page 315 Appendix Refugee Referral to IWD and to Refugee Services Revised April 6, 2012 470-0480

Refugee Referral to IWD and to Refugee Services, Form 470-0480 Purpose

Form 470-0480 is used in the Refugee Cash Assistance program to refer an employable refugee to the Iowa Workforce Development (IWD) and to the Bureau of Refugee Services. IWD uses the form to register the refugee for employment. The Bureau of Refugee Services uses the form to register the refugee for employment or training and to notify the local Department office when registration is complete.

Source

Complete form 470-0480 on line using the template on the DHS Intranet eForms web page.

Completion

The IM worker prepares the form, except for the IWD signature and date and the Bureau of Refugee Services’ signature and date. Prepare this form: ♦ At the time of application for those refugees determined to be employable. ♦ At any time a refugee who has been exempt from employment is no longer exempt and must register for employment.

Distribution

Give two copies to the refugee to take to IWD when registering for work. You may upload the request to the electronic case file. IWD returns the form to the refugee, who mails the form to the Bureau of Refugee Services. The Bureau of Refugee Services keeps a copy and returns the original to the IM worker. When scanning center receives the completed copy, it will be scanned and uploaded.

Data

This form identifies the refugee and the IM worker.

Iowa Department of Human Services Employees’ Manual

Title 6: Income Maintenance Programs Appendix Revised April 6, 2012

Page 404 Comm. 20 or Comm. 20(S) Your Guide to Medicaid

Comm. 20 or Comm. 20(S), Your Guide to Medicaid Purpose

Booklet Comm. 20 or Comm. 20(S) gives basic information about the services covered under the Medicaid Program.

Source

Printed supplies of Comm. 20 or Comm. 20(S) may be ordered from Iowa Prison Industries at Anamosa.

Distribution

Give this booklet to Medicaid applicants or other interested persons.

Data

The booklet describes the use of the Medical Assistance Eligibility Card, retroactive eligibility, copayment and other member responsibilities, who can provide covered services, the coverage limitations applicable to the various providers, managed care, and use of the Member Services Call Center.

Iowa Department of Human Services Employees’ Manual

Comm. 20 (Rev. 1/12)

Your Guide to Medicaid

Table of Contents Part I: Basic Medicaid Information Your Medical Assistance Eligibility Card ............................................................................................. 1 Retroactive Medicaid Eligibility ........................................................................................................... 1 Who Can Provide Services................................................................................................................. 2 Providers.................................................................................................................................... 2 Away from Home ....................................................................................................................... 2 Managed Care ........................................................................................................................... 2 Copayments ....................................................................................................................................... 2 Limits to Medicaid-Covered Services ................................................................................................. 3 Member Responsibilities .................................................................................................................... 4 Member Services Call Center ............................................................................................................. 4 Appeals and Hearings ........................................................................................................................ 6

Part II: Basic Medicaid Benefits Ambulance ......................................................................................................................................... 6 Birth Control and Family Planning Clinics ........................................................................................... 6 Case Management (Targeted) ........................................................................................................... 7 Chiropractic Services ......................................................................................................................... 7 Clinics................................................................................................................................................. 7 Dental Services .................................................................................................................................. 7 Doctor Visits ....................................................................................................................................... 8 Emergency Room Care ...................................................................................................................... 8 Eye Exams and Eyeglasses ............................................................................................................... 9 Hearing Services ................................................................................................................................ 9 Home Health Care.............................................................................................................................. 9 Hospice Care ................................................................................................................................... 10 Hospital and Urgent Care ................................................................................................................. 10 Lab and X-ray ................................................................................................................................... 10 Maternity Care and Birth Center Services ........................................................................................ 11 Medical Equipment and Supplies ..................................................................................................... 11 Mental Health Services (Psychologists and Social Workers) ............................................................ 11 Midwife Services .............................................................................................................................. 12 Nursing Home Services .................................................................................................................... 12 Medicare-Certified Skilled Nursing Facilities ............................................................................ 12 Nurse Anesthetists and Nurse Practitioners ..................................................................................... 12 Certified Registered Nurse Anesthetists (CRNAs) ................................................................... 12 Advanced Registered Nurse Practitioners (ARNPs) ................................................................ 12

Comm. 20 (Rev. 1/12)

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Podiatry and Orthopedic Shoes ........................................................................................................ 13 Prescriptions and Over-the-Counter Drugs ...................................................................................... 13 Rural Health Clinics .......................................................................................................................... 14 Therapy Services (Occupational, Physical, and Speech) ................................................................. 14 Tobacco Cessation (Quit Smoking) .................................................................................................. 15 Transportation Services ................................................................................................................... 15 Non-Emergency Medical Transportation (NEMT) .................................................................... 15 Other Transportation Services ................................................................................................. 16 Waiver Programs.............................................................................................................................. 16

Part III: Other Program Benefits Ambulatory Surgical Centers ............................................................................................................ 17 Behavioral Health Intervention Services (BHIS) ............................................................................... 17 Children’s Services ........................................................................................................................... 17 Early and Periodic Screening, Diagnosis and Treatment (EPSDT) “Care for Kids” .................. 17 Infant and Toddler Services ..................................................................................................... 18 Community Mental Health Centers ................................................................................................... 18 Estate Recovery Program ................................................................................................................ 18 Federally Qualified Health Centers ................................................................................................... 18 Habilitation Services—Home- and Community-Based Services (HCBS) .......................................... 18 Health Insurance Premium Payment (HIPP) .................................................................................... 19 AIDS/HIV Health Insurance Premium Payment (HIPP) ............................................................ 19 Intermediate Care Facilities for Persons with Mental Retardation and Related Conditions (ICF/MR) .......................................................................................................................................... 19 Iowa Plan for Behavioral Health ....................................................................................................... 19 Local or Area Education Services .................................................................................................... 20 Managed Health Care ...................................................................................................................... 20 Program for All-Inclusive Care for the Elderly (PACE) ...................................................................... 21

Comm. 20 (Rev. 1/12)

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Your Guide to Medicaid Part I: Basic Medicaid Information This guide tells you what Medicaid covers (pays for) and how to use the program.

 Keep this guide! Use it to learn more about your Medicaid benefits.

Your Medical Assistance Eligibility Card All members receive a new Medical Assistance Eligibility Card, form 470-1911.

♦ ♦ ♦ ♦

Keep your card until you receive a new one. Always carry your card with you and don’t let anyone else use it. Show your card to the provider every time you get care. If you lose your card, call Member Services to ask for a new one.

Member Services: 1-800-338-8366 Member Services in the Des Moines area: 1-515-256-4606

Retroactive Medicaid Eligibility You may qualify for Medicaid for up to three months before the month you applied. These months are called the “retroactive period.” You can qualify for retroactive benefits only if all of these statements are true:

♦ You have medical bills for services that you received during the retroactive period. (The bills can be paid or unpaid.) ♦ The bills are for services covered by Medicaid. ♦ You would have qualified for Medicaid in the months you got services, if you had applied. There are two exceptions:

♦ The IowaCare coverage group allows only one retroactive month, which is the month before the month of your application. ♦ These groups do not allow retroactive benefits: • • • •

Iowa family planning network (IFPN) Home- and community-based services waiver Program for all-inclusive care for the elderly (PACE) Qualified Medicare beneficiary (QMB)

 Call your local Department of Human Services (DHS) office if you think you or a family member qualifies for retroactive Medicaid.

Comm. 20 (Rev. 1/12)

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Who Can Provide Services Providers With Medicaid, you will choose your own providers. Follow these steps: 1.

To search for a provider, you can go to: https://secureapp.dhs.state.ia.us/providersearche/.

2.

Choose a doctor, dentist, pharmacy, and other providers that take Medicaid.

3.

Ask the providers if they take Medicaid before you make an appointment. Some providers limit their number of Medicaid patients or don’t take Medicaid.  Remember: Make sure the provider understands that you are in Iowa Medicaid. If you don’t say you are an Iowa Medicaid member before you get services—and the provider doesn’t take Medicaid—you may be billed for the entire cost!

4.

Show your Medical Assistance Eligibility Card when you get to the appointment.

5.

Ask if Medicaid covers the service you need or if you will have to pay for it.

Away from Home If you are out of Iowa and need medical care, check to see whether the provider is enrolled with Iowa Medicaid. A provider who is enrolled with Iowa Medicaid, must accept what Medicaid pays. Providers are not allowed to charge you for services that Medicaid covers. If the provider does not participate in Medicaid, you will have to pay for the services.

Managed Care Some Medicaid members get health care through MediPASS or an HMO. Read more about MediPASS and HMOs on page 20. Mental Health and Substance Abuse (Behavioral Health)

♦ Read about how to get these services through the Iowa Plan on page 19. Program of All-Inclusive Care for the Elderly (PACE)

♦ Read about how to get these services through PACE on page 21.

Copayments Some medical services have a copayment, which is your share of the cost. If there is a copayment, you will pay it to the provider. The provider will tell you how much it is.

Comm. 20 (Rev. 1/12)

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There is a copayment:

♦ If federal rules require one. ♦ If the service is not a service Medicaid requires but the state chooses to cover it. Examples are dental services and prescription drugs. ♦ For emergency room service if the visit is not an emergency. There is no co-payment:

♦ ♦ ♦ ♦

For care covered by Medicaid in a skilled nursing facility or nursing facility. If you are pregnant. If you are under age 21. For services provided by a health maintenance organization (HMO).

Limits to Medicaid-Covered Services Limits to Medicaid-covered services include:

♦ Limits to coverage for abortion and sterilization Ask your medical provider if an abortion or sterilization is covered for you. You must sign a consent form for sterilization and then wait 30 days, except in premature delivery or if emergency abdominal surgery is performed not less than 72 hours after you sign the form. This is a federal Medicaid rule.

♦ Limits to coverage for organ and tissue transplants Only certain types of transplants are covered. For some transplants, you must get approval before the transplant. Your provider should know what types of transplants are covered and when approval is needed.

♦ No coverage for surgery for obesity without approval before the surgery Only certain types of surgeries for obesity are covered, even with approval. Your medical care provider should know what is covered. The provider will ask for the approval.

♦ No coverage for cosmetic, plastic or reconstructive surgery to improve appearance or for psychiatric purposes. ♦ No coverage for flatfoot treatment and routine foot care, such as cutting or removing corns or calluses and trimming nails. ♦ No coverage for acupuncture treatments.

Comm. 20 (Rev. 1/12)

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Member Responsibilities As a Medicaid member, you must:

♦ Keep all appointments you make with providers or call to cancel or reschedule. Some providers may stop seeing you if you miss one or more scheduled appointments. ♦ Ask only for medical services that are medically necessary. DHS may limit your services if you use Medicaid for services that are not necessary. ♦ Tell Iowa Medicaid Member Services about any changes to other health insurance coverage. Tell them if coverage ends, if you lose or get new coverage or if you change insurance companies. ♦ Tell your medical providers about anyone else who may be legally responsible to pay your medical bills. ♦ Report to Iowa Medicaid Member Services if you are injured in an accident or if you claim medical negligence for something that required medical treatment. ♦ Report any settlements you get from lawsuits, insurance claims or worker’s compensation claims. Medicaid can be denied or canceled if you don’t tell DHS about these settlements. ♦ If you were in a trauma-related incident, you or your representative must contact the Iowa Medicaid Enterprise (IME) Revenue Collections/Lien Recovery Unit before any documents will be released. Call 1-888-543-6742 or 1-515-256-4620 in the Des Moines area.

Member Services Call Center The Member Services Call Center toll-free telephone numbers are: 1-800-338-8366 and 1-515-256-4606 in the Des Moines area. Call your Member Services Call Center for questions about:

♦ Changing your address ♦ Asking for a new card (except for IowaCare) ♦ Getting general Medicaid information ♦ Enrolling in Managed Health Care (MHC) ♦ Getting approvals (prior authorizations) ♦ Getting special approvals (special authorizations) ♦ Asking about third-party liability (TPL) Medicaid is a “payer of last resort.” This means that any other insurance you have must be billed first.

♦ Billing

Comm. 20 (Rev. 1/12)

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If you are calling about unpaid bills you think Medicaid should have covered, have these things ready when you call:

♦ The medical bill ♦ A brief description of the services provided ♦ The member ID number on the Medical Assistance Eligibility Card for the person who received the billed services You may also write or fax the Member Services Call Center at: The Iowa Medicaid Enterprise Attention: Billing PO Box 36510 Des Moines, IA 50315 Fax number: 515-725-1351 Or go to http://www.ime.state.ia.us or email us at [email protected]. Contact your local DHS office:

♦ If you move ♦ If you have a change in income ♦ At the birth of a child ♦ At the death of a Medicaid member ♦ If you need to add an authorized caller ♦ To ask about Medical Assistance, Food Assistance, Family Investment Program or Child Care Assistance Call the DHS Call Center at 1-877-347-5678:

♦ ♦ ♦ ♦ ♦ ♦

If you need an IowaCare card To correct the spelling of your name To change your name because of marriage or divorce To update the number of persons who live in your household To change a date of birth or Social Security number To report a gain or loss in financial resources

Comm. 20 (Rev. 1/12)

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Appeals and Hearings Talk to a worker if you disagree with a decision DHS makes.

♦ You have the right to file an appeal asking for a hearing. ♦ You must file the appeal within 30 days of the date on the notice. ♦ Talking with your worker or DHS staff does not extend this time limit. The hearings are completed by a conference call over the phone. You can present your complaint by phone during the meeting. The judge will review all the facts and find whether the decision was correct or should be changed. You must ask for the appeal by writing to your local DHS office, or you may write to: Iowa Department of Human Services Appeals Section 5th Fl 1305 E Walnut Des Moines, IA 50319-0114 You may also file an appeal at http://www.dhs.state.ia.us/forms/appealrequest.htm.

Part II: Basic Medicaid Benefits Ambulance When seconds count, call 911 for an ambulance. Tell the ambulance driver to take you to the nearest hospital. But remember, Medicaid will pay for ambulance transportation to a hospital or skilled nursing facility only when it would be dangerous for your health for you to go on your own. Medicaid may cover an air ambulance when a ground ambulance can’t get you to care fast enough. If an ambulance is called to your home and you decline transport, Iowa Medicaid will not pay for the charges. You may be billed and be responsible for payment.

Birth Control and Family Planning Clinics Medicaid family planning services include counseling, medical exams, laboratory tests, medications and supplies for family planning. You can get these supplies from any provider who takes Medicaid or your health plan. Medicaid covers:

♦ Most birth control drugs and supplies. Brand-name birth control drugs or supplies may need your doctor’s approval. ♦ Oral contraceptives prescribed in 90-day supplies.

Comm. 20 (Rev. 1/12)

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Case Management (Targeted) Targeted case management makes it easier to get help with your medical care and social needs. Case management services are available to Medicaid members with:

♦ Mental retardation ♦ Developmental disabilities ♦ Chronic mental illness Targeted case management services include:

♦ Talking to the case manager to be sure all services and living-arrangement needs are identified ♦ Help to make sure there is an individual comprehensive plan (ICP) that addresses the total need for services and living arrangements ♦ Help getting the services and living arrangements in the ICP ♦ Help to make sure all providers follow the ICP ♦ Monitoring services and living arrangements to make sure they are still appropriate ♦ Help getting a referral to the appropriate provider in a crisis ♦ Discharge-planning activities for institutionalized persons: •

For no more than 60 days before the estimated discharge date

•

For case manager discharge activities different from the institution’s discharge-planning activities

Chiropractic Services Except for members who are pregnant or under the age of 18, Medicaid covers only this chiropractic service:

♦ Chiropractic Manipulative Therapy (CMT). Subluxation or misalignment of the spine that is proven by an x-ray

Clinics Clinic services have the same coverage and limits as doctors and hospitals.

Dental Services Dental services may include teeth cleaning, fillings, extractions, disease control, and surgery. Dental services have these limits:

♦ Routine exam: 1 time every 6 months ♦ Teeth cleaning: 1 time every 6 months

Comm. 20 (Rev. 1/12)

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♦ Bitewing x-ray: 1 time every 12 months ♦ Complete x-ray: 1 time every 5 years, unless there is a need ♦ Crown: 2 crowns 1 time a year, nonprecious metal ♦ Sealant: only 1 time per tooth ♦ Dentures: 1 time every 5 years ♦ Complete exam: only once per dental provider This is a more thorough exam done if you have never been to that dentist or have not been to the dentist in 3 years.

 Contact your local I-Smile Coordinator if you need help finding a dentist who will see your child under 21 years of age. You can find your I-Smile Coordinator by calling 1-866-764-5315 toll-free or going to http://www.idph.state.ia.us/webmap/default.asp?map=ismile.

Doctor Visits Medicaid covers these services performed in an office, clinic, hospital, your own home or other places:

♦ Medical and surgical services ♦ Diagnostic tests ♦ X-rays ♦ Treatment procedures ♦ Physical exams once a year with basic lab tests for members, including children and newly settled refugees, if they qualify Limits to these services are listed on page 3.

Emergency Room Care Go to an emergency room when you have a serious medical problem and it’s not safe to wait. Examples of true emergencies are:

♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦

Heavy bleeding Chest pain Trouble breathing Bad burns Broken bone Choking Blacking out (fainting) Suddenly unable to move or speak Poisoning

Comm. 20 (Rev. 1/12)

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There is no copay when the member is:

♦ ♦ ♦ ♦ ♦

In need of emergency service, or Admitted to a hospital for inpatient stay, or Under age 21, or Pregnant, or Receiving family planning services

 Members may have a copayment when the visit is not for a true emergency. Also, members on MediPASS may be billed for emergency room visits that are not a true emergency if they do not have a referral from their primary care physician.

Eye Exams and Eyeglasses Vision services may include eye exams, glasses, repairs to glasses and visual aids. Covered services include:

♦ ♦ ♦ ♦ ♦ ♦ ♦

Lens correction Protective lenses New frames Safety frames Contact lenses Replacement glasses Vision exams

 Contact Member Services for more information on eye care services.

Hearing Services Medicaid covers hearing tests and will pay for hearing aids, batteries, supplies and repairs if you need hearing aids. Hearing services have these limits:

♦ Hearing aids: 1 time every 4 years per ear ♦ Hearing exams: 1 time every 4 years per ear

Home Health Care Home health services can be given in the member’s home by a Medicare-certified home health agency for an illness or injury. Types of care in your home include:

♦ Skilled nursing care ♦ Physical, occupational or speech therapy

Comm. 20 (Rev. 1/12)

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♦ Medical social services ♦ Home health aide  To be covered by Medicaid, these services must be medically necessary to treat illness or injury and ordered by your physician. Medicaid does not cover:

♦ Home care services to help people meet personal family and domestic needs ♦ Full-time nursing care at home ♦ Private-duty nursing services at home, except for persons up to age 21 when the care is medically necessary and pre-authorized and exceeds the benefits provided through skilled nursing and home health aides

Hospice Care Hospice provides care to members who are terminally ill and wish to be comfortable and peaceful when they are dying. Hospice care can be given wherever the member is living. Hospice services provided by a home health agency are covered if the agency has been certified to participate in Medicare and Medicaid. Services can include nursing, hospice aide, social work, chaplain, volunteers, and durable medical equipment.

Hospital and Urgent Care Medicaid covers both inpatient and outpatient hospital care, with some limits. You may have a copayment when an emergency room visit is not for a true emergency. Go to your own doctor or to an urgent care clinic instead of an emergency room for:

♦ ♦ ♦ ♦ ♦ ♦

Sprained wrist or ankle Earache Cough Fever Vomiting Medical supplies and equipment

Lab and X-ray Medicaid covers many lab and x-ray services. Be sure to ask whether the test is covered. If it is not covered, you will have to pay for it.

Comm. 20 (Rev. 1/12)

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Maternity Care and Birth Center Services Maternal health centers provide:

♦ ♦ ♦ ♦

Prenatal care (care during pregnancy) Health education Nutritional services Social services and case management

Birth center services provide:

♦ Prenatal care ♦ Delivery ♦ Postpartum care (after the birth)

Medical Equipment and Supplies Medicaid may cover medical equipment and supplies that you need. Your doctor must write an order for equipment and supplies. Examples of equipment and supplies Medicaid covers:

♦ ♦ ♦ ♦

Wheelchairs Prosthetic devices Bandages or wound-care supplies Oxygen and supplies

Medicaid does not cover:

♦ ♦ ♦ ♦ ♦

Air conditioners Dehumidifiers Blenders Massage devices Exercise equipment

Mental Health Services (Psychologists and Social Workers) Mental health services are covered if they are provided by a psychologist or social worker who is employed by a hospital, a home health or rehabilitation agency, a community mental health center or a doctor. Payment goes to the person or organization that employs the psychologist or social worker. Medicaid may pay for the services of a:

♦ Mental health counselor ♦ Marital and family counselor ♦ Certified drug counselor Comm. 20 (Rev. 1/12)

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Medicaid may also pay for covered services by a provider in private practice. See the Iowa Plan services on page 19.

Midwife Services Covered services include prenatal, delivery, and postpartum care and other services allowed by state law. The provider must be a Medicaid provider. The limits are the same as for doctors. Payment will be made only to certified nurse-midwives who are advanced registered nurse practitioners. Medicaid will not pay lay nurse-midwives who are not advanced registered nurse practitioners.

Nursing Home Services Medicare-Certified Skilled Nursing Facilities Medicaid helps with the cost of care in a nursing facility. A doctor must certify that you need nursing care, not a hospital, and that you qualify for medical assistance. The Iowa Medicaid Enterprise Medical Services Unit must confirm this. Medicaid may also cover the cost of care if you need the services of a certified skilled nursing facility. You may keep part of your income for personal needs. The rest goes for the nursing home cost, unless the Family Investment Program (FIP) is your income source.

 Make sure you qualify both medically and financially for care in a nursing home. If you are admitted to a nursing home and later found not medically or financially eligible for medical assistance, Medicaid will not pay for any care you received.

Nurse Anesthetists and Nurse Practitioners Certified Registered Nurse Anesthetists (CRNAs) Medicaid will pay for services allowed by state law and given by certified registered nurse anesthetists. The limits are the same as for doctors. If a CRNA is employed by a doctor, hospital or clinic, Medicaid pays the provider that employs the CRNA. Medicaid may also pay CRNAs who are in independent practice.

Advanced Registered Nurse Practitioners (ARNPs) Medicaid will pay for services allowed by state law and given by nurse practitioners. The limits are the same as for doctors. Medicaid may directly pay nurse practitioners who:

♦ Are enrolled providers with Iowa Medicaid ♦ Practice in a specialty recognized by the Iowa Board of Nursing

Comm. 20 (Rev. 1/12)

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Podiatry and Orthopedic Shoes Medicaid covers:

♦ Foot surgery ♦ Certain prosthetic appliances for the foot Medicaid does not cover:

♦ Treatments for flatfoot ♦ Routine foot care, such as clipping nails or treatment of corns and calluses Orthopedic shoes, shoes for persons with diabetes, inserts and modifications are covered only if prescribed in writing by a doctor, a physician’s assistant or an advanced registered nurse practitioner. If you don’t have a written prescription, you must pay for the shoes.

Prescriptions and Over-the-Counter Drugs Most prescription drugs and some over-the-counter drugs are covered. A doctor or qualified medical practitioner must write the order or prescription. For some drugs, you must get approval from Medicaid first. Pharmacists must give you the lowest-cost item in stock that meets your provider’s order. They must also give you (or your caregiver) information about how to use any drug you receive. For most drugs, the first prescription must be for a 31-day supply. Some prescriptions cannot be for more than a 15-day supply at first. Refills can then be up to the normal 31-day supply. Your pharmacist may refill a prescription only when you have used 85% of the supply:

♦ Refills for a 30-day supply are allowed after 26 days. ♦ Refills for a 90-day supply are allowed after 77 days.  Ask your pharmacist for an exception if you need a longer supply or early refill of a drug or supply for reasons such as travel. All birth control drugs and supplies are covered.

♦ If there is a generic drug, you will need approval for certain brand-name birth control drugs. ♦ Your pharmacist, doctor and other providers should know what is covered and what drugs need approval first. ♦ Oral contraceptives may be prescribed in 90-day supplies.

Comm. 20 (Rev. 1/12)

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Prescription drugs that are not covered include:

♦ ♦ ♦ ♦ ♦

Most cough and cold medications Weight-loss drugs Drugs for cosmetic reasons such as hair growth Fertility drugs Erectile dysfunction drugs

Over-the-counter drugs are in regular packages, usually in 100-unit quantities. You may get up to a 31-day supply. You may get up to a 90-day supply of all covered medical supplies. Covered over-the-counter drugs include:

♦ ♦ ♦ ♦

Aspirin Acetaminophen (Tylenol) Multiple vitamins and minerals for pregnant and nursing women Multiple vitamins and minerals (with prior approval)

You must show your Medical Assistance Eligibility Card to your pharmacist to pay for prescription and over-the-counter drugs or supplies. If Medicaid will not pay for a drug or supply the doctor ordered, your pharmacist can explain why. If you are not satisfied with the explanation, you may contact Iowa Medicaid Member Services. If you are still not satisfied, you can demand a formal, written notice of decision that explains your right to appeal.

Rural Health Clinics Services provided by a rural health clinic are covered if the clinic is certified to participate in Medicare and Medicaid. Covered services can include doctor services, nurse practitioner and physician’s assistant services, visiting nurse services, and other ambulatory services.

Therapy Services (Occupational, Physical, and Speech) Therapy services are covered when the therapist is employed by a hospital, home health or rehabilitation agency, nursing home or doctor. Services provided by occupational and physical therapists in their own independent practice are covered if the therapist is certified and participates in Medicaid. Medicaid does not cover services of independent speech therapists. There are yearly limits on the amount that can be paid, unless you get the services at a hospital outpatient department.

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Tobacco Cessation (Quit Smoking) You must first make an appointment with your provider. Together, you and your doctor will decide on the best plan for you. Medicaid covers these drugs to quit smoking:

♦ ♦ ♦ ♦

Chantix Buproprion (generic for Zyban) Nicotine-replacement patches Nicotine gum

If your provider chooses Chantix, over-the-counter nicotine-replacement patches or gum, you must get Quitline Iowa counseling. Here is how to join Quitline Iowa: 1.

Fill out an authorization form at your provider's office.

2.

Your provider will fax the form to Quitline Iowa.

3.

Quitline Iowa will contact you for information and enroll you.

4.

Quitline Iowa will send a form to Iowa Medicaid for your medication.

5.

Pick up your medication at your pharmacy once Iowa Medicaid approves it.

Transportation Services Non-Emergency Medical Transportation (NEMT) Non-emergency medical transportation provides members with transportation or reimbursement (money paid back) for travel to medical, dental, pharmacy, and mental health appointments or services. TMS is the agency that provides help with transportation. Medicaid members who need a ride or want reimbursement for medical travel expenses through TMS must:

♦ Call TMS at 1-866-572-7662 at least three business days before the medical trip or appointment ♦ Give TMS your full name, state ID number, address, phone number, and trip dates ♦ Give TMS the name, address, phone number, and fax number of your medical provider TMS will:

♦ Assess your transportation needs ♦ Make sure you qualify ♦ Make sure the medical provider is an Iowa Medicaid provider

Comm. 20 (Rev. 1/12)

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♦ Make sure the service is an Iowa Medicaid covered service ♦ Ask for any additional information needed about the trip ♦ Make sure the medical trip meets the federal and state requirements for non-emergency medical transportation travel and reimbursement TMS will give the member a confirmation number when the trip is booked. Members who want reimbursement after the medical trip must send TMS:

♦ The confirmation number ♦ The claim form ♦ All receipts  Learn more about non-emergency medical transportation at http://www.ime.state.ia.us/members/index.html.  Medical transportation is not covered under Iowa Family Planning Network (IFPN). Other Transportation Services Local transportation is also available for children under age 21 and pregnant women for travel to medical or dental care at local programs.

 Ask your local Care for Kids or maternal health care coordinators to arrange transportation for you.  For contact information, call the Healthy Families Line at 1-800-369-2229.

Waiver Programs You may qualify for a waiver program if you need care in a medical facility but would rather stay at home or would return home if the services you need could be arranged. Medical facilities include hospitals, nursing facilities or intermediate care facilities for individuals with mental retardation. Iowa has seven home- and community-based services (HCBS) waiver programs:

♦ ♦ ♦ ♦ ♦ ♦ ♦

AIDS/HIV waiver Brain injury waiver Children’s mental health waiver Elderly waiver Ill and handicapped waiver Intellectual disability waiver Physical disability waiver

 Contact the local office of the Iowa Department of Human Services to see if you qualify for a waiver program. Comm. 20 (Rev. 1/12)

Page 16

Part III: Other Program Benefits Ambulatory Surgical Centers Services provided by an ambulatory surgical center are covered if the center is certified to participate in Medicare and Medicaid. Medicaid covers surgical services that are medically necessary, with the same limits as for doctor services.

Behavioral Health Intervention Services (BHIS) BHIS services are provided through the Iowa Plan (see page 19). The services provide support, direction and teaching interventions in a community-based or residential group-care environment. Services are designed to improve the adult or child’s level of functioning related to a mental illness. The main goal is to help the member and the member’s family to learn age-appropriate skills to manage behavior and have self-control.

Children’s Services Early and Periodic Screening, Diagnosis and Treatment (EPSDT) “Care for Kids” EPSDT covers health screening for children up to the age of 21 who get Medicaid. Medicaid will cover any follow-up services needed as a result of the screening. A complete screening examination includes:

♦ Health and developmental history ♦ Well child physical examination and measurements ♦ Vision and hearing screening ♦ Oral (mouth) health assessment  Children over the age of 12 months should see a dentist. ♦ Mental health and nutritional assessment ♦ Lab tests ♦ Immunizations (shots) ♦ Health education  For help finding a provider, making an appointment or getting transportation, call the Healthy Families Line at 1-800-369-2229.

Comm. 20 (Rev. 1/12)

Page 17

Infant and Toddler Services Medical services are provided through the Early Access program. These services are covered for children ages 0 through 3:

♦ ♦ ♦ ♦ ♦ ♦ ♦

Developmental assessments Audiology (hearing) Nursing Nutrition Occupational and physical therapy Speech/language therapy Vision

 For help, call 1-888-IAK-IDS1 (888-425-4371) or go to: http://www.earlyaccessiowa.org.

Community Mental Health Centers Medicaid may cover services by a psychiatrist, psychologist, social worker or psychiatric nurse. The provider must be on the staff of a DHS-certified community mental health center.

Estate Recovery Program Estate recovery means that after your death the state will try to get back the cost of your medical bills that Medicaid paid. The state will collect from the assets you have at the time of your death. Estate recovery applies to all persons who get Medicaid on or after July 1, 1994, and are age 55 or older or who live in a medical facility and will most likely not be able to return home.

Federally Qualified Health Centers These services are covered, with the same limits as for doctors and dentists.

Habilitation Services—Home- and Community-Based Services (HCBS) These services are designed to meet the needs of members with a history of chronic mental illness. A team led by a case manager will write a comprehensive service plan identifying needed services. Covered services include:

♦ ♦ ♦ ♦

Home-based habilitation Day habilitation Pre-vocational services Supported employment

Comm. 20 (Rev. 1/12)

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Health Insurance Premium Payment (HIPP) This program helps Medicaid members get or keep health insurance. HIPP helps by paying for the insurance premium. To qualify for HIPP:

♦ You or someone in your home must have Medicaid. ♦ You must have health insurance or be able to get it through your employer. ♦ The health insurance must be cost-effective. AIDS/HIV Health Insurance Premium Payment (HIPP) The AIDS/HIV HIPP program helps people living with AIDS/HIV-related illness. It pays their health insurance premiums when they become too ill to work. To qualify for services under the AIDS/HIV HIPP program, the person must:

♦ Not qualify for Medicaid ♦ Be a resident of Iowa ♦ Provide a doctor's certification that the person cannot work because of AIDS or HIV-related illness ♦ Be the health insurance plan policy holder or a dependent on the spouse’s plan ♦ Have “liquid” assets (cash, stocks, bank accounts, etc.) of less than $10,000 ♦ Meet the income limits  To apply or contact HIPP, call 1-888-346-9562 toll-free, or email [email protected], or go to http://www.dhs.state.ia.us/hipp.

Intermediate Care Facilities for Persons with Mental Retardation and Related Conditions (ICF/MR) An ICF/MR provides 24-hour care and services for persons with mental retardation or other related conditions.

♦ Services must be provided in a licensed facility setting. ♦ Persons must first be eligible for Medicaid and approved by the Iowa Medicaid Enterprise Medical Services.  Contact the DHS local office to learn more about this program.

Iowa Plan for Behavioral Health Most Medicaid members are enrolled in the Iowa Plan for Behavioral Health (Iowa Plan). The Iowa Plan is a statewide managed care program for mental health services and substance abuse treatment. Ask about the Iowa Plan toll-free at 1-800-317-3738.

Comm. 20 (Rev. 1/12)

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If you are enrolled in the Iowa Plan:

♦ You have the right to know how to get these Medicaid benefits. ♦ You will receive an information packet soon after you qualify for Medicaid. ♦ You can call the toll-free number if you have questions about mental health or substance abuse services. To find a provider through the Iowa Plan, call the toll-free number for a list of providers. Or you may go directly to a provider to get care. Show your Medicaid card to the provider so the provider can check to see if you are in the Iowa Plan. If your provider is not part of the Iowa Plan, the provider may want to join or refer you to another provider. In a mental health or substance abuse emergency, go directly to a hospital emergency room to be evaluated for appropriate care and treatment.

Local or Area Education Services Medicaid may cover these services provided by local or area education agencies:

♦ ♦ ♦ ♦ ♦ ♦

Physical therapy Occupational therapy Speech therapy Mental health services Hearing services Nursing Services

Managed Health Care If you are an Iowa Medicaid member and live in a county where there is Managed Health Care, you may be required to join a plan. This does not take away any Medicaid benefits. You may choose either a health maintenance organization (HMO) or a MediPASS doctor. IME will assign a provider if you do not choose. With managed health care:

♦ You have a primary care doctor. ♦ You build a doctor–patient relationship. ♦ When you need medical services, you have a phone number to call and a doctor and staff who know you. ♦ You get the medical care you need from your own doctor instead of from an impersonal emergency room or a doctor you don’t know. ♦ It’s easier for you and your children to get preventive services to stay healthy—things like shots for children and a yearly PAP and pelvic exam for women.

Comm. 20 (Rev. 1/12)

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Managed Health Care changes the way you get some medical services, so be sure to read about your choices and how to get Medicaid services in Managed Health Care. You will get more written information once you choose (or are assigned if you don’t choose).

 Call Member Services workdays from 8:00 a.m. to 5:00 p.m. at 1-800-338-8366, or 1-515-256-4606 in the Des Moines area. You can also call if you have any problems after you are enrolled or if you want to change your enrollment. You may ask for a change if you’re not happy with your choice or if your circumstances change (for example, if you move or your doctor retires).

Program for All-Inclusive Care for the Elderly (PACE) PACE helps Medicaid members stay healthy and live in the community as long as possible. A PACE program will coordinate and provide all preventive, primary, in-home acute and long-term care services for persons age 55 and older.

 Contact Member Services workdays from 8:00 a.m. to 5:00 p.m. at 1-800-338-8366, or 1-515-256-4606 in the Des Moines area to tell you if you live in a county that has a PACE program. The Member Services representative will give you contact information for the PACE program.

Comm. 20 (Rev. 1/12)

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Comm. 20(S) (Rev. 1/12)

Su Guía de Medicaid (Your Guide to Medicaid)

Contenido Parte I: Información Básica Sobre Medicaid Su Tarjeta de Elegibilidad para Asistencia Médica ............................................................................. 1 Elegibilidad Retroactiva para Medicaid............................................................................................... 1 Quiénes Pueden Prestar Servicios ..................................................................................................... 2 Proveedores .............................................................................................................................. 2 En Caso de Viajar ...................................................................................................................... 2 Servicios Médicos Administrados (Managed Care) .................................................................... 2 Copagos ............................................................................................................................................. 2 Limitaciones de los Servicios Cubiertos por Medicaid ........................................................................ 3 Responsabilidades de los Miembros .................................................................................................. 4 Centro Telefónico de Servicios para Miembros .................................................................................. 4 Apelaciones y Audiencias................................................................................................................... 6

Parte II: Beneficios Básicos de Medicaid Ambulancia ........................................................................................................................................ 6 Clínicas de Planeamiento Familiar y Control de la Natalidad ............................................................. 6 Gestión de Casos (Orientada) ............................................................................................................ 7 Servicios de Quiropráctica.................................................................................................................. 7 Clínicas .............................................................................................................................................. 7 Servicios Odontológicos ..................................................................................................................... 7 Visitas al Médico ................................................................................................................................ 8 Atención en Salas de Emergencia...................................................................................................... 8 Examen de la Vista y Lentes .............................................................................................................. 9 Servicios de la Audición ..................................................................................................................... 9 Servicios Médicos a Domicilio ............................................................................................................ 9 Servicio de Hospicio ......................................................................................................................... 10 Atención Hospitalaria y Urgencias .................................................................................................... 10 Análisis y Radiografías ..................................................................................................................... 10 Servicios en Centros de Maternidad y Parto .................................................................................... 11 Equipo y Suministros Médicos ......................................................................................................... 11 Servicios de Salud Mental (Psicólogos y Asistentes Sociales) ......................................................... 11 Servicios de Partera ......................................................................................................................... 12 Servicios en Sanatorios .................................................................................................................... 12 Centros Especializados Acreditados por Medicare .................................................................. 12 Personal de Enfermería Especializado en Anestesia y Medicina General........................................ 12 Enfermeros-Anestesistas Acreditados y Registrados (CRNA) ................................................. 12 Profesionales Registrados de Enfermería Avanzada (ARNP) .................................................. 12

Comm. 20(S) (Rev. 1/12)

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Podología y Calzado Ortopédico ...................................................................................................... 13 Medicamentos bajo Receta y Medicamentos de Venta Libre ........................................................... 13 Clínicas Rurales ............................................................................................................................... 14 Servicios de Terapia (Ocupacional, Física, y del Habla y el Lenguaje) ............................................ 14 Tratamiento Antitabaco (Dejar de Fumar) ........................................................................................ 15 Servicios de Transporte ................................................................................................................... 15 Transporte de Rutina - Sin Emergencia (NEMT)...................................................................... 15 Otros Servicios de Transporte ................................................................................................. 16 Programas de Exención (Waiver) ..................................................................................................... 16

Parte III: Beneficios de Otros Programas Centros Quirúrgicos Ambulatorios .................................................................................................... 17 Servicios de Intervención para la Salud Conductual (BHIS) ............................................................. 17 Servicios para Niños y Adolescentes ............................................................................................... 17 Exámenes Periódicos, Diagnóstico Temprano y Tratamiento (EPSDT) “Care for Kids”........... 17 Servicios para Bebés y Niños .................................................................................................. 18 Centros Comunitarios de Salud Mental ............................................................................................ 18 Programa de Cobro a través del Patrimonio Sucesorio .................................................................... 18 Centros de Salud Acreditados a Nivel Federal ................................................................................. 18 Servicios de Habilitación—Servicios Comunitarios y a Domicilio (HCBS) ........................................ 18 Pago de Primas del Seguro Médico (HIPP) ..................................................................................... 19 Pago de Primas del Seguro Médico para SIDA/VIH (HIPP) ..................................................... 19 Instituciones de Cuidado Intermedio para Personas con Retardo Mental y otras Condiciones Relacionadas (ICF/MR) .................................................................................................................... 19 Plan de Iowa para la Salud Conductual ............................................................................................ 19 Servicios Educativos Locales o Regionales ..................................................................................... 20 Servicios Médicos Administrados ..................................................................................................... 20 Programa para Adultos Mayores con Todos los Servicios Incluidos (PACE) ................................... 21

Comm. 20(S) (Rev. 1/12)

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Su Guía de Medicaid Parte I: Información Básica Sobre Medicaid Esta guía le informa qué servicios cubre (paga) Medicaid y cómo usar el programa.

 ¡Consérvela! Úsela para informarse más sobre las prestaciones de Medicaid.

Su Tarjeta de Elegibilidad para Asistencia Médica Todos los miembros recibirán una nueva Tarjeta de Elegibilidad para Asistencia Médica, formulario 470-1911.

♦ ♦ ♦ ♦

Conserve su tarjeta hasta que reciba la nueva. Llévela siempre con usted y no permita que otras personas la usen. Muéstrele su tarjeta a los proveedores de servicios cada vez que reciba atención médica. Si la pierde, llame a Servicios para Miembros y solicite una tarjeta nueva.

Servicios para Miembros: 1-800-338-8366 Servicios para Miembros en el área de Des Moines: 1-515-256-4606

Elegibilidad Retroactiva para Medicaid Puede calificar para cobertura hasta tres meses antes de solicitar Medicaid. Estos meses se llaman “período retroactivo”. Puede calificar para beneficios retroactivos únicamente si se cumplen todas las siguientes condiciones:

♦ Tiene facturas médicas por servicios que recibió durante el período retroactivo. (Las facturas pueden haber sido pagadas o estar impagas.) ♦ Las facturas son por servicios cubiertos por Medicaid. ♦ Habría calificado para Medicaid durante los meses que recibió servicios, si lo hubiera solicitado. Hay dos excepciones:

♦ La cobertura grupal de IowaCare permite sólo un mes retroactivo, es decir el mes anterior a la presentación de la solicitud. ♦ Los siguientes grupos no permiten beneficios retroactivos: • • • •

Iowa family planning network (IFPN) – Red de planeamiento familiar de Iowa Home- and community-based services waiver – Servicios de exención comunitarios y a domicilio Program for all-inclusive care for the elderly (PACE) – Programa para adultos mayores con todos los servicios incluidos Qualified Medicare beneficiary (QMB) – Beneficiario calificado de Medicare

 Llame a la oficina local de Department of Human Services (DHS) si cree que usted o un miembro de su familia califica para beneficios retroactivos de Medicaid. Comm. 20(S) (Rev. 1/12) Página 1

Quiénes Pueden Prestar Servicios Proveedores Con Medicaid, podrá elegir a sus proveedores. Siga estos pasos: 1.

Para buscar proveedores, consulte: https://secureapp.dhs.state.ia.us/providersearche/.

2.

Elija un médico, un dentista, una farmacia y otros proveedores que acepten Medicaid.

3.

Pregúnteles a los proveedores si aceptan Medicaid antes de hacer una cita. Algunos proveedores atienden a una cantidad limitada de pacientes con Medicaid o no lo aceptan.  Recuerde: Asegúrese de que el proveedor comprenda que es miembro de Medicaid de Iowa. Si no se lo dice antes de recibir servicios y el proveedor no acepta Medicaid, ¡tendrá que pagar el costo total de los servicios!

4.

Cuando vaya a la cita, muestre su Tarjeta de Elegibilidad para Asistencia Médica.

5.

Pregunte si Medicaid cubre el servicio que necesita o si tendrá que pagarlo usted mismo/a.

En Caso de Viajar Si viaja fuera de Iowa y necesita atención médica, verifique que el proveedor esté registrado con Medicaid de Iowa. Todos los proveedores registrados con Medicaid de Iowa deben aceptar lo que Medicaid les paga y está prohibido que le cobren los servicios cubiertos por Medicaid. Si el proveedor no forma parte de la red de Medicaid, usted tendrá que pagar por los servicios.

Servicios Médicos Administrados (Managed Care) Algunos miembros de Medicaid reciben atención médica a través de MediPASS o de una HMO (Organización administradora de servicios médicos). Encontrará más información sobre MediPASS y las HMO en la página 20. Salud Mental y Drogadicción (Salud Conductual)

♦ Para averiguar cómo conseguir estos servicios a través del Plan de Iowa, consulte la página 19. Programa para adultos mayores con todos los servicios incluidos (PACE)

♦ Para averiguar cómo conseguir estos servicios a través de PACE, consulte la página 21.

Copagos Algunos servicios médicos tienen copago, es decir que debe pagar una parte del costo. En dicho caso, le abonará el copago directamente al proveedor. El proveedor le informará cuánto debe pagar. Comm. 20(S) (Rev. 1/12)

Página 2

Se debe pagar copago:

♦ Si las normas federales lo exigen. ♦ Si Medicaid no exige dichos servicios pero el estado ha decidido cubrirlos, por ejemplo: servicios odontológicos y recetas para medicamentos. ♦ Por servicios en una sala de emergencias si no se tratara de una urgencia. No se abona copago:

♦ ♦ ♦ ♦

Por servicios cubiertos por Medicaid en centros de atención especializada o en sanatorios. Si está embarazada. Si es menor de 21 años. Por servicios provistos por una HMO.

Limitaciones de los Servicios Cubiertos por Medicaid Las limitaciones de los servicios cubiertos por Medicaid comprenden:

♦ Limitaciones de la cobertura en el caso de aborto y esterilización. Pregúntele a su proveedor médico si el aborto o la esterilización están cubiertos en su caso. Deberá firmar un formulario de consentimiento para que se realice la esterilización y luego esperar 30 días, excepto en el caso de parto prematuro o si se debe realizar cirugía abdominal de emergencia en no menos de 72 horas de haber firmado el formulario. Esta es una norma de Medicaid a nivel federal.

♦ Limitaciones de la cobertura en el caso de trasplantes de órganos o de tejidos Sólo ciertos tipos de trasplantes están cubiertos. En el caso de algunos trasplantes, se debe conseguir autorización antes del trasplante. Su proveedor le informará qué tipos de trasplantes están cubiertos y si se necesita autorización.

♦ No está cubierta la cirugía por obesidad sin autorización previa a la cirugía Están cubiertos sólo ciertos tipos de cirugías por obesidad, aún sin autorización. Su proveedor médico le informará qué cirugías están cubiertas y solicitará la autorización.

♦ No están cubiertas la cirugía cosmética, la cirugía plástica ni la cirugía reconstructiva con el fin de mejorar la apariencia o con propósitos psiquiátricos. ♦ No está cubierto el tratamiento para pie plano ni la pedicuría de rutina, como recortar las uñas o extraer callosidades. ♦ No están cubiertos los tratamientos con acupuntura.

Comm. 20(S) (Rev. 1/12)

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Responsabilidades de los Miembros En calidad de miembro de Medicaid, debe:

♦ Cumplir con todas las citas con los proveedores o llamar para cancelarlas o reprogramarlas. Algunos proveedores podrían decidir no tenerle como paciente si no asiste a una o más de las citas programadas. ♦ Solicitar solamente aquellos servicios que son necesarios por razones de salud. DHS podrá limitar sus servicios si utiliza Medicaid para servicios que no son necesarios. ♦ Informar a los Servicios para Miembros de Iowa Medicaid sobre los cambios que se produzcan en otras coberturas de seguro médico. Infórmeles si la cobertura finaliza, si pierde la cobertura o consigue una nueva, o si cambia de compañía de seguro. ♦ Informarles a sus proveedores médicos sobre aquellas personas que tienen la obligación legal de pagar sus facturas médicas. ♦ Informar a los Servicios para Miembros de Iowa Medicaid si sufre lesiones en un accidente o si inicia una demanda por negligencia médica debido a que no recibió tratamiento médico cuando éste era necesario. ♦ Informar sobre la resolución de demandas judiciales, reclamaciones a seguros o al seguro de accidentes laborales. Los beneficios de Medicaid serán denegados o cancelados si no le informa a DHS sobre la resolución de los mismos. ♦ Si sufre un traumatismo durante un incidente, usted o su representante deben comunicarse con Revenue Collections/Lien Recovery Unit (Unidad de cobro de rentas o gravámenes) de Iowa Medicaid Enterprise (IME) antes que se expida la documentación. Llame al teléfono 1-888-543-6742 o al 1-515-256-4620 en el área de Des Moines.

Centro Telefónico de Servicios para Miembros Los números telefónicos gratuitos del Centro de Servicios para Miembros son: 1-800-338-8366 y 1-515-256-4606 en el área de Des Moines. Llame al Centro Telefónico de Servicios para Miembros si desea consultar sobre:

♦ Cambio de domicilio ♦ Solicitud de una nueva tarjeta (excepto para IowaCare) ♦ Información general sobre Medicaid ♦ Inscripción en Managed Health Care (MHC) (Servicios médicos administrados) ♦ Aprobación de servicios (autorizaciones previas) ♦ Aprobación de servicios especiales (autorizaciones especiales) ♦ Información sobre responsabilidad de terceros (third-party liability, TPL) Medicaid es la institución encargada de pagar gastos médicos “como último recurso”. Esto significa que primero se deben facturar los gastos médicos a cualquier otro seguro que usted tenga.

♦ Facturación Comm. 20(S) (Rev. 1/12)

Página 4

Si llama para consultar sobre factures impagas que en su opinión Medicaid debería haber cubierto, tenga a mano lo siguiente cuando llame:

♦ La factura médica. ♦ Una breve descripción de los servicios provistos. ♦ El número de identificación que figura en la tarjeta Medical Assistance Eligibility Card del miembro que recibió los servicios facturados. Además, puede escribir o enviar un fax al Centro Telefónico de Servicios para Miembros a: The Iowa Medicaid Enterprise Attention: Billing PO Box 36510 Des Moines, IA 50315 Fax: 515-725-1351 O dirigirse a http://www.ime.state.ia.us o enviarnos un correo electrónico a [email protected]. Comuníquese con la oficina local de DHS:

♦ Si se muda ♦ Si sus ingresos cambian ♦ Por el nacimiento de un bebé ♦ Por el fallecimiento de un miembro de Medicaid ♦ Si necesita agregar a una persona con autorización para llamar ♦ Para averiguar sobre Medical Assistance (asistencia médica), Food Assistance (asistencia para alimentos), Family Investment Program (el programa de inversión familiar, FIP) o Child Care Assistance (asistencia para cuidado infantil o guardería) Llame al Centro Telefónico de DHS al número 1-877-347-5678:

♦ ♦ ♦ ♦ ♦ ♦

Si necesita una tarjeta de IowaCare Para corregir un error de ortografía en su nombre Para cambiar su nombre debido a casamiento o divorcio Para actualizar la cantidad de personas que viven en su vivienda Para cambiar una fecha de nacimiento o un número de Social Security Para informar sobre la pérdida o la obtención de recursos económicos

Comm. 20(S) (Rev. 1/12)

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Apelaciones y Audiencias Hable con un asistente si no está de acuerdo con una decisión tomada por DHS.

♦ Tiene derecho a presentar una apelación y solicitar una audiencia. ♦ Debe presentar la apelación dentro de los 30 días posteriores a la fecha que figura en la notificación. ♦ Hablar con su asistente o con personal de DHS no extiende el límite de 30 días. Las audiencias se realizan mediante llamadas en teleconferencia. Puede presentar su queja por teléfono durante la reunión. El juez analizará todos los hechos y decidirá si la decisión fue correcta o si debería ser cambiada. Debe solicitar la apelación por escrito a la oficina local de DHS o por carta a: Iowa Department of Human Services Appeals Section 5th Fl 1305 E Walnut Des Moines, IA 50319-0114 También puede presentar la apelación en http://www.dhs.state.ia.us/forms/appealrequest.htm.

Parte II: Beneficios Básicos de Medicaid Ambulancia En el caso de una emergencia en que cada segundo que pasa es fundamental, llame al 911 para pedir una ambulancia. Dígale al conductor de la ambulancia que le lleve al hospital más cercano. Pero recuerde, Medicaid pagará el transporte en ambulancia para ir a un hospital o un centro médico especializado únicamente cuando sería peligroso para su salud que fuera por sus propios medios. Medicaid podría cubrir el costo de una ambulancia aérea en el caso de que una ambulancia terrestre no le pudiera llevar lo suficientemente rápido para recibir atención médica. Si pide una ambulancia y cuando ésta llega a su hogar, usted rehúsa el servicio, Iowa Medicaid no pagará los gastos. Usted recibirá la factura y será responsable del pago.

Clínicas de Planeamiento Familiar y Control de la Natalidad Los servicios de planeamiento familiar de Medicaid incluyen orientación, exámenes médicos, análisis de laboratorio, medicamentos y suministros para planeamiento familiar. Puede obtener dichos suministros a través de de su plan médico o de cualquier proveedor que acepte Medicaid. Medicaid cubre:

♦ La mayoría de los suministros y los medicamentos para control de la natalidad. Los suministros y los medicamentos para control de la natalidad con marcas comerciales necesitarán la aprobación de su médico. ♦ Anticonceptivos orales recetados para 90 días. Comm. 20(S) (Rev. 1/12)

Página 6

Gestión de Casos (Orientada) La gestión orientada facilita que reciba asistencia para atención médica y sus necesidades sociales. Los servicios de gestión de casos están disponibles para miembros de Medicaid con:

♦ Retardo mental ♦ Discapacidades del desarrollo ♦ Enfermedades mentales crónicas Los servicios de la gestión orientada incluyen:

♦ Hablar con el gestor del caso para asegurarse de que se identifiquen todos los servicios necesarios y la residencia necesaria. ♦ Ayuda para estar seguro de que existe un plan integral personalizado (individual comprehensive plan, ICP) que aborde totalmente la necesidad de servicios y de servicios residenciales. ♦ Ayuda para conseguir los servicios y los servicios residenciales que figuran en el ICP. ♦ Ayuda para cerciorarse de que todos los proveedores siguen el ICP. ♦ Monitoreo de los servicios y la residencia para asegurarse de que siguen siendo adecuados. ♦ Ayuda para conseguir remisión a un proveedor apropiado en caso de crisis. ♦ Actividades orientadas al plan de alta en el caso de personas que estén recluidas: •

Por no más de 60 días antes de la fecha estimada del alta.

•

En el caso de que las actividades del gestor de casos sean diferentes a las del plan de alta de la institución.

Servicios de Quiropráctica Medicaid cubre solamente los siguientes servicios de quiropráctica, excepto en el caso de miembros que estén embarazadas o sean menores de 18 años:

♦ Fisioterapia manual (Chiropractic Manipulative Therapy, CMT). Subluxación o desviación de la columna vertebral comprobada por medio de radiografía.

Clínicas Los servicios clínicos tienen la misma cobertura y las mismas limitaciones que los médicos y los hospitales.

Servicios Odontológicos Los servicios odontológicos pueden incluir limpieza dental, arreglo de caries, extracciones, control de enfermedades y cirugía. Los servicios odontológicos tienen las siguientes limitaciones:

♦ Examen de rutina: 1 vez cada 6 meses ♦ Limpieza dental: 1 vez cada 6 meses Comm. 20(S) (Rev. 1/12)

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♦ Radiografía dental tipo “bitewing”: 1 vez cada 12 meses ♦ Radiografía completa: 1 vez cada 5 años, a menos que sea necesario ♦ Corona: 2 coronas 1 vez al año, metales no preciosos ♦ Sellador dental: sólo 1 vez por cada pieza dental ♦ Dentadura postiza: 1 vez cada 5 años ♦ Examen completo: solamente una vez por proveedor de servicios odontológicos Éste es un examen más meticuloso que se realiza durante la primera visita o si no ha ido al dentista por 3 años.

 Comuníquese con su Coordinador local de I-Smile si necesita ayuda para encontrar a un dentista para sus hijos menores de 21 años. Llame gratis al 1-866-764-5315 o visite http://www.idph.state.ia.us/webmap/default.asp?map=ismile para localizar a su Coordinador de I-Smile.

Visitas al Médico Medicaid cubre los siguientes servicios en consultorios, clínicas, hospitales, su propio hogar u otros lugares:

♦ Servicios médicos y quirúrgicos ♦ Exámenes diagnósticos ♦ Radiografías ♦ Tratamientos y procedimientos médicos ♦ Examen físico una vez por año con análisis básicos para miembros, incluso niños y refugiados recién llegados, si califican Las limitaciones de estos servicios figuran en la página 3.

Atención en Salas de Emergencia Diríjase a una sala de emergencia cuando tenga un problema grave y esperar podría ser peligroso. Ejemplos de emergencias verdaderas:

♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦

Hemorragia abundante Dolor en el pecho Problemas para respirar Quemaduras graves Fracturas Asfixia Desvanecimiento (desmayo) Imposibilidad repentina de moverse o de hablar Intoxicación

Comm. 20(S) (Rev. 1/12)

Página 8

No se abona copago si el miembro:

♦ ♦ ♦ ♦ ♦

Necesita servicios de emergencia, o Es admitido para hospitalización, o Es menor de 21 años, o Está embarazada, o Recibe servicios de planeamiento familiar.

 Los miembros podrían tener que abonar copago si la visita no se debe a una emergencia verdadera. Además, a los miembros que tengan MediPASS se les podrá facturar las visitas a la sala de emergencias cuando no sea una urgencia si los mismos no fueron remitidos por su médico de atención primaria.

Examen de la Vista y Lentes Los servicios oftalmológicos pueden incluir exámenes de la vista, reparación de lentes y dispositivos visuales. Los servicios cubiertos incluyen:

♦ ♦ ♦ ♦ ♦ ♦ ♦

Lentes correctoras Lentes protectoras Marcos nuevos Marcos de seguridad Lentes de contacto Lentes de reemplazo Exámenes de la vista

 Comuníquese con Servicios para Miembros para obtener más información sobre los servicios oftalmológicos.

Servicios de la Audición Medicaid cubre exámenes auditivos y pagará audífonos, baterías, suministros y reparaciones si necesita audífonos. Los servicios auditivos tienen las siguientes limitaciones:

♦ Audífonos: 1 vez cada 4 años para cada oído ♦ Exámenes auditivos: 1 vez cada 4 años en cada oído

Servicios Médicos a Domicilio Los servicios médicos a domicilio se ofrecen debido a enfermedad o lesión a través de una agencia de servicios médicos a domicilio que posea la acreditación de Medicare. Tipos de servicios médicos a domicilio:

♦ Enfermería especializada ♦ Fisioterapia, terapia ocupacional y terapia del habla y el lenguaje Comm. 20(S) (Rev. 1/12)

Página 9

♦ Servicios médico-sociales ♦ Auxiliar de servicios médicos a domicilio  Medicaid cubre estos servicios cuando los mismos son necesarios para tratar enfermedades y lesiones desde el punto de vista clínico y los mismos hayan sido ordenados por un médico. Medicaid no cubre:

♦ Servicios médicos a domicilio con el fin de ayudar a la gente a cumplir con sus necesidades personales, familiares y domésticas. ♦ Servicios de enfermería de tiempo completo en el hogar ♦ Servicios privados de enfermería en el hogar, excepto en el caso de menores hasta la edad de 21 años cuando los servicios sean necesarios desde el punto de vista clínico, hayan sido autorizados previamente y excedan los beneficios provistos por servicios de enfermería especializada y auxiliares médicos a domicilios.

Servicio de Hospicio El servicio de hospicio les brinda cuidados a los miembros con enfermedades terminales que deseen sentirse cómodos y en paz hasta el momento de su muerte. Los servicios de hospicio se ofrecen en el lugar donde el miembro esté viviendo. Los servicios de hospicio provistos por una agencia de servicios médicos a domicilio están cubiertos si dicha agencia está acreditada para participar en Medicare y Medicaid. Los servicios pueden incluir enfermería, auxiliar de hospicio, asistente social, capellán, voluntarios y equipo médico duradero.

Atención Hospitalaria y Urgencias Medicaid cubre la atención hospitalaria de pacientes internos y externos, con algunas limitaciones. Tendrá que abonar copago si visita la sala de emergencias debido a una afección que no sea una emergencia verdadera. Visite a su propio médico o una clínica de urgencias debido a:

♦ ♦ ♦ ♦ ♦ ♦

Esguince de muñeca o de tobillo Dolor de oído Tos Fiebre Vómitos Suministros y equipo médico

Análisis y Radiografías Medicaid cubre muchos servicios de análisis de laboratorio y radiografías. Pregunte si el estudio está cubierto. Si no estuviera cubierto, usted tendrá que pagarlo.

Comm. 20(S) (Rev. 1/12)

Página 10

Servicios en Centros de Maternidad y Parto Los centros de maternidad ofrecen los siguientes servicios:

♦ ♦ ♦ ♦

Atención prenatal (atención médica durante el embarazo) Educación para la salud Servicios nutricionales Servicios sociales y gestión de casos

Los centros de parto y nacimiento ofrecen los siguientes servicios:

♦ Atención prenatal ♦ Parto ♦ Atención posparto (después del nacimiento)

Equipo y Suministros Médicos Medicaid podría cubrir el equipo y los suministros médicos que necesite. Su médico debe escribir la orden para el equipo y los suministros. Ejemplos de equipo y suministros cubiertos por Medicaid:

♦ ♦ ♦ ♦

Sillas de ruedas Prótesis Vendajes y suministros para el cuidado y tratamiento de heridas Oxígeno y suministros

Medicaid no cubre:

♦ ♦ ♦ ♦ ♦

Acondicionadores de aire Deshumidificadores Licuadoras Dispositivos para masajes Máquinas para hacer ejercicio

Servicios de Salud Mental (Psicólogos y Asistentes Sociales) Los servicios de salud mental están cubiertos si son provistos por psicólogos o asistentes sociales contratados por hospitales, agencias de servicios médicos a domicilio o de rehabilitación, centros comunitarios de salud mental o por médicos. El pago se realiza a la persona o a la organización que contrata al psicólogo o al asistente social. Medicaid podría pagar los servicios de:

♦ Psicoterapeutas ♦ Consejeros matrimoniales y familiares ♦ Terapeutas acreditados en drogadicción

Comm. 20(S) (Rev. 1/12)

Página 11

Medicaid también podría pagar los servicios cubiertos y provistos por un proveedor particular. Vea los servicios del Plan de Iowa en la página 19.

Servicios de Partera Los servicios cubiertos incluyen atención prenatal, parto, atención posparto y otros servicios permitidos por las leyes estatales. Los proveedores deben ser proveedores de Medicaid. Las limitaciones son las mismas que para los médicos. El pago se hará únicamente a personal de enfermería acreditado y especializado en partos que estén registrados y posean estudios avanzados. Medicaid no pagará los servicios de parteras sin acreditación, que no estén registradas, ni posean estudios avanzados.

Servicios en Sanatorios Centros Especializados Acreditados por Medicare Medicaid ayuda a pagar el costo de la atención en sanatorios. Un médico debe certificar que usted necesita atención en un sanatorio, no en un hospital, y que califica para asistencia médica. La Unidad de Servicios Médicos de Iowa Medicaid Enterprise debe confirmarlo. Medicaid también podría cubrir el costo de la atención en el caso de que necesitara los servicios de un centro acreditado de atención especializada. Puede conservar parte de sus ingresos para necesidades personales. El resto se acredita al pago del sanatorio, a menos que su principal fuente de ingresos sea el programa FIP (Family Investment Program).

 Cerciórese de calificar tanto médica como económicamente para atención en un sanatorio. Si es admitido/a y más tarde se descubre que no es elegible para asistencia médica, Medicaid no pagará los cuidados recibidos.

Personal de Enfermería Especializado en Anestesia y Medicina General Enfermeros-Anestesistas Acreditados y Registrados (CRNA) Medicaid pagará los servicios permitidos por las leyes estatales y provistos por enfermerosanestesistas acreditados y registrados. Las limitaciones son las mismas que para los médicos. Si un CRNA es empleado de un médico, hospital o clínica, Medicaid le paga al proveedor que emplea al CRNA. Medicaid también les podría pagar a CRNA que practiquen la medicina en forma independiente.

Profesionales Registrados de Enfermería Avanzada (ARNP) Medicaid pagará los servicios permitidos por las leyes estatales y provistos por enfermeros profesionales. Las limitaciones son las mismas que para los médicos. Medicaid podría pagarles directamente a los enfermeros profesionales que:

♦ Están inscriptos como proveedores de Iowa Medicaid. ♦ Ejercen la profesión en una especialidad reconocida por el Iowa Board of Nursing. Comm. 20(S) (Rev. 1/12)

Página 12

Podología y Calzado Ortopédico Medicaid cubre:

♦ Cirugía de los pies ♦ Determinadas prótesis para el pie Medicaid no cubre:

♦ Tratamiento para pie plano ♦ Cuidados de rutina, tales como recortar las uñas o el tratamiento de callosidades y durezas. Están cubiertos el calzado ortopédico, el calzado para diabéticos, las plantillas y las modificaciones únicamente si fueron recetados por escrito por un médico, un médico asistente o un profesional registrado de enfermería avanzada. Si no tiene la receta, deberá pagar el calzado usted mismo.

Medicamentos bajo Receta y Medicamentos de Venta Libre Están cubiertos la mayoría de los medicamentos bajo receta y algunos medicamentos de venta libre. Un médico o un profesional médico calificado debe escribir la orden o la receta. En el caso de algunos fármacos, primero debe conseguir autorización de Medicaid. Los farmacéuticos deben entregarle el artículo de menor costo que tengan en stock y que cumpla con la orden de su proveedor. Además, deben informarle a usted o a la persona a cargo de su cuidado cómo se usa el medicamento que le entrega. Para la mayoría de los medicamentos, la primera receta debe ser por una cantidad suficiente para 31 días. Algunas recetas no se pueden hacer por cantidades que superen los 15 días al principio. Las siguientes recetas podrán hacerse por la cantidad normal para 31 días. Su farmacéutico podrá volver a surtir una receta sólo cuando se haya usado el 85% de la provisión:

♦ Una provisión para 30 días puede surtirse después de 26 días. ♦ Una provisión para 90 días puede surtirse después de 77 días.  Pídale a su farmacéutico que haga una excepción si por alguna razón, como por ejemplo un viaje, necesita una provisión de medicamentos por más tiempo o que se los entregue antes del tiempo permitido. Todos los fármacos y suministros para control de la natalidad están cubiertos.

♦ En el caso de que exista un medicamento genérico, necesitará autorización para determinados medicamentos con nombres comerciales. ♦ Su farmacéutico, su médico u otros proveedores le informarán cuáles están cubiertos y qué fármacos necesitan autorización previa. ♦ Las recetas para anticonceptivos orales se pueden hacer por 90 días.

Comm. 20(S) (Rev. 1/12)

Página 13

Los medicamentos bajo receta que no están cubiertos son:

♦ La mayoría de los medicamentos para la tos y el resfrío ♦ Medicamentos para adelgazar ♦ Medicamentos con propósitos cosméticos, como por ejemplo un fármaco para hacer crecer el cabello ♦ Medicamentos para incrementar la fertilidad ♦ Medicamentos para la disfunción eréctil Los medicamentos de venta libre vienen en envases regulares que generalmente contienen 100 unidades. Le entregarán una provisión para 31 días como máximo. Le entregarán una provisión para 90 días de todos los suministros médicos cubiertos. Los medicamentos de venta libre que están cubiertos son:

♦ ♦ ♦ ♦

Aspirina Acetaminofén o paracetamol (Tylenol) Múltiples vitaminas y minerales para embarazadas y mujeres que estén amamantando Múltiples vitaminas y minerales (con autorización previa)

Debe mostrarle su tarjeta Medical Assistance Eligibility Card al farmacéutico para pagar la receta y los medicamentes y suministros de venta libre. En el caso de que Medicaid no pague alguno de los medicamentos y suministros ordenados por su médico, su farmacéutico le explicará el motivo. Si no se siente conforme con la explicación dada, puede comunicarse con los Servicios para Miembros de Medicaid en Iowa. Si aún sigue disconforme, puede demandar que le envíen una notificación de resolución formal y por escrito donde le expliquen su derecho a apelar.

Clínicas Rurales Los servicios provistos por las clínicas rurales están cubiertos si las mismas están acreditadas para participar en Medicare y Medicaid. Los servicios cubiertos pueden incluir los servicios de médicos, profesionales de enfermería y médicos asistentes, servicios de enfermería a domicilio y otros servicios ambulatorios.

Servicios de Terapia (Ocupacional, Física, y del Habla y el Lenguaje) Los servicios terapéuticos están cubiertos cuando los terapeutas son empleados de un hospital, de una agencia de rehabilitación o de servicios médicos a domicilio, de un sanatorio o de un médico. Se cubren los servicios provistos por terapeutas ocupacionales y fisioterapeutas en su propio consultorio si los mismos están acreditados y participan en Medicaid. Medicaid no cubre los servicios de terapeutas del habla y el lenguaje que sean independientes. Existen límites anuales sobre la cantidad que se puede pagar, a menos que reciba servicios en el departamento ambulatorio de un hospital.

Comm. 20(S) (Rev. 1/12)

Página 14

Tratamiento Antitabaco (Dejar de Fumar) Primero debe hacer una cita con su proveedor médico. Juntos, usted y su médico decidirán el mejor plan para usted. Medicaid cubre los siguientes medicamentos para dejar de fumar:

♦ ♦ ♦ ♦

Chantix Bupropion (genérico para Zyban) Parches sustitutos de nicotina Chicles con nicotina

Si su proveedor elige Chantix, parches o chicles de venta libre deberá recibir servicios terapéuticos de Quitline de Iowa. Para participar en Quitline de Iowa: 1.

Llene el formulario de autorización en el consultorio de su proveedor médico.

2.

Su proveedor enviará el formulario por fax a Quitline de Iowa.

3.

Quitline de Iowa se comunicará con usted para pedirle sus datos y hacer la inscripción.

4.

Quitline de Iowa le enviará un formulario a Iowa Medicaid para su medicación.

5.

Pase a buscar sus medicamentos por su farmacia una vez que Iowa Medicaid los haya aprobado.

Servicios de Transporte Transporte de Rutina - Sin Emergencia (NEMT) Este servicio les brinda a los miembros transporte o reembolso de gastos (se les devuelve el dinero) por viajes a las citas o los servicios con médicos, dentistas, farmacias y salud mental. TMS es la agencia que ofrece asistencia para transporte. Los miembros de Medicaid que necesiten transporte o deseen que se les reintegren los gastos de viajes a través de TMS deben:

♦ Llamar a TMS al teléfono 1-866-572-7662 por lo menos 3 días hábiles antes del viaje o de la cita médica. ♦ Darle a TMS su nombre completo, número de identificación estatal, domicilio, número de teléfono y fechas del viaje. ♦ Darle a TMS el nombre, domicilio, número de teléfono y número de fax de su proveedor médico. TMS hará lo siguiente:

♦ Evaluará su necesidad de transporte ♦ Se cerciorará de que usted califica para servicios de transporte ♦ Comprobará que el proveedor médico es proveedor de Iowa Medicaid

Comm. 20(S) (Rev. 1/12)

Página 15

♦ Verificará que el servicio está cubierto por Iowa Medicaid ♦ Solicitará información extra que sea necesaria para el viaje ♦ Comprobará que el viaje cumple con los requisitos federales y estatales para transporte médico de rutina y reintegro TMS le dará al miembro un número de confirmación cuando haga la reserva para el viaje. Los miembros que deseen reintegro después del viaje, le deben enviar a TMS:

♦ El número de confirmación ♦ El formulario de reclamo ♦ Todos los recibos  Para obtener más información sobre el transporte médico de rutina, visite http://www.ime.state.ia.us/members/index.html.  El transporte médico no está cubierto por la Red de Planeamiento Familiar de Iowa (Iowa Family Planning Network, IFPN). Otros Servicios de Transporte El transporte local también está disponible para menores de 21 años y embarazadas que necesiten trasladarse para atención médica y odontológica de los programas locales.

 Pídales a los coordinadores de Care for Kids o del programa de salud maternal que programen su transporte.  Para obtener la información de contacto, llame al servicio telefónico de Healthy Families al teléfono 1-800-369-2229.

Programas de Exención (Waiver) Puede calificar para programas especiales si necesita atención en instituciones médicas pero preferiría quedarse en su casa o regresar a su casa si fuera posible recibir servicios allí. Las instituciones médicas incluyen hospitales, sanatorios o instituciones de cuidado intermedio para individuos con retardo mental. Iowa tiene siete programas especiales de servicios comunitarios y a domicilio (HCBS):

♦ ♦ ♦ ♦ ♦ ♦ ♦

AIDS/HIV waiver – Programa para enfermos con SIDA/VIH Brain injury waiver – Programa para enfermos con lesiones cerebrales Children’s mental health waiver – Programa de salud mental para niños Elderly waiver – Programa para adultos mayores Ill and handicapped waiver – Programa para enfermos y discapacitados Intellectual disability waiver – Programa de discapacidad intelectual Physical disability waiver – Programa de discapacidad física

 Comuníquese con la oficina local de Iowa Department of Human Services para ver si califica para alguno de los programas de exención. Comm. 20(S) (Rev. 1/12) Página 16

Parte III: Beneficios de Otros Programas Centros Quirúrgicos Ambulatorios Los servicios provistos por los centros quirúrgicos ambulatorios están cubiertos si dichos centros están acreditados para participar en Medicare y Medicaid. Medicaid cubre los servicios quirúrgicos que sean necesarios desde el punto de vista clínico, con las mismas limitaciones que los servicios provistos por los médicos.

Servicios de Intervención para la Salud Conductual (BHIS) Los servicios BHIS se ofrecen a través del Plan de Iowa (ver página 19). Estos servicios brindan intervenciones de ayuda psicológica, orientación y educación en ambientes comunitarios y residenciales de atención grupal. Los servicios están diseñados para mejorar el nivel de funcionamiento de adultos y menores de edad con enfermedades mentales. El principal objetivo es ayudar al miembro y a su familia a aprender sobre las capacidades adecuadas de acuerdo a la edad del miembro con el fin de manejar la conducta y lograr autocontrol.

Servicios para Niños y Adolescentes Exámenes Periódicos, Diagnóstico Temprano y Tratamiento (EPSDT) “Care for Kids” EPSDT cubre los exámenes de control hasta la edad de 21 años. Medicaid cubrirá todos los servicios que se consideren necesarios como resultado del examen de control. Un examen completo incluye:

♦ Historia clínica y del desarrollo ♦ Examen físico y mediciones ♦ Examen de la vista y de la audición ♦ Examen de la salud bucal (dental)  Los niños mayores de 12 meses deben ver al dentista. ♦ Evaluación psicológica y nutricional ♦ Análisis de laboratorio ♦ Inmunizaciones (vacunas) ♦ Educación para la salud  Para recibir ayuda para encontrar a un proveedor, hacer una cita o conseguir transporte, llame al servicio telefónico de Healthy Families al 1-800-369-2229.

Comm. 20(S) (Rev. 1/12)

Página 17

Servicios para Bebés y Niños Los servicios médicos se ofrecen a través del programa Early Access. Los siguientes servicios se cubren desde el nacimiento y hasta los 3 años:

♦ ♦ ♦ ♦ ♦ ♦ ♦

Evaluaciones del desarrollo Audiología (audición) Enfermería Nutrición Terapia ocupacional y fisioterapia Terapia del habla y el lenguaje Visión

 Si necesita asistencia, llame al 1-888-IAK-IDS1 (888-425-4371) o visite: http://www.earlyaccessiowa.org.

Centros Comunitarios de Salud Mental Medicaid podría cubrir los servicios provistos por psiquiatras, psicólogos, asistentes sociales y enfermeros psiquiátricos. Los proveedores deben pertenecer al personal de un centro comunitario de salud mental que esté acreditado por DHS.

Programa de Cobro a través del Patrimonio Sucesorio “Cobro a través del patrimonio sucesorio” significa que después de su fallecimiento, el estado tratará de cobrar el costo de las facturas médicas que Medicaid pagó. El estado se cobrará de los bienes que usted tenga en el momento de su fallecimiento. Esta política se aplica a todas las personas que han recibido Medicaid desde el 1 de julio de 1994 y que tienen 55 años o más, o que viven en una institución médica y que probablemente no podrán regresar a su hogar.

Centros de Salud Acreditados a Nivel Federal Estos servicios están cubiertos, con las mismas limitaciones que para los médicos y los dentistas.

Servicios de Habilitación—Servicios Comunitarios y a Domicilio (HCBS) Estos servicios están diseñados para satisfacer las necesidades de los miembros con historial de enfermedad mental crónica. Un equipo dirigido por un gestor de casos escribirá un plan integral de servicios donde se identificarán los servicios necesarios. Los servicios cubiertos incluyen:

♦ ♦ ♦ ♦

Habilitación a domicilio Habilitación diaria Servicios pre-vocacionales Empleo con apoyo

Comm. 20(S) (Rev. 1/12)

Página 18

Pago de Primas del Seguro Médico (HIPP) Este programa ayuda a los miembros de Medicaid a conseguir o a conservar su seguro médico. HIPP les ayuda pagando la prima del seguro. Para calificar para HIPP:

♦ Usted o alguien en su hogar debe tener Medicaid. ♦ Usted debe tener seguro médico o debe poder conseguirlo a través de su empleador. ♦ El seguro médico deber ser rentable. Pago de Primas del Seguro Médico para SIDA/VIH (HIPP) El programa HIPP para SIDA/VIH les ayuda a las personas que sufren enfermedades relacionadas con SIDA/VIH. Les paga las primas del seguro médico cuando están demasiado enfermas para trabajar. Para calificar para los servicios de este programa, es necesario que:

♦ No califique para Medicaid ♦ Sea residente de Iowa ♦ Presente la certificación de un médico indicando que no puede trabajar debido a una enfermedad relacionada con SIDA o VIH ♦ Sea el titular de la póliza del plan del seguro médico o figure como dependiente en el plan de su cónyuge ♦ Posea activos “líquidos” (efectivo, acciones, cuentas bancarias, etc.) por un importe inferior a $10,000 ♦ Reúna los requisitos sobre límites de ingresos  Para presentar la solicitud o comunicarse con HIPP, llame gratis al 1-888-346-9562 o envíe un correo electrónico a [email protected], o visite http://www.dhs.state.ia.us/hipp.

Instituciones de Cuidado Intermedio para Personas con Retardo Mental y otras Condiciones Relacionadas (ICF/MR) Las ICF/MR brindan atención y servicios por 24 horas a personas con retardo mental y otras condiciones relacionadas.

♦ Los servicios deben brindarse en instituciones acreditadas. ♦ Las personas primero deben ser elegibles para Medicaid y recibir autorización de los Servicios Médicos de Iowa Medicaid Enterprise.  Comuníquese con la oficina local de DHS para averiguar sobre este programa.

Plan de Iowa para la Salud Conductual La mayoría de los miembros de Medicaid están inscriptos en el Plan de Iowa para la Salud Conductual (Plan de Iowa). El Plan de Iowa es un programa administrado a nivel estatal para servicios de salud mental y el tratamiento de la drogadicción. Averigüe sobre el Plan de Iowa llamando gratis al 1-800-317-3738.

Comm. 20(S) (Rev. 1/12)

Página 19

Si está in inscripto/a en el Plan de Iowa:

♦ Tiene derecho a saber cómo obtener estos beneficios de Medicaid. ♦ Recibirá un paquete informativo poco después de calificar para Medicaid. ♦ Puede llamar al número de llamada gratuita si desea hacer preguntas sobre los servicios de salud mental y drogadicción. Para encontrar a un proveedor a través del Plan de Iowa, llame al número de llamada gratuita para obtener el listado de proveedores, o puede dirigirse directamente a un proveedor para recibir atención. Muéstrele su tarjeta de Medicaid al proveedor para que éste verifique que usted pertenece al Plan de Iowa. Si su proveedor no participa en el Plan de Iowa, el proveedor podría registrarse o hacer la remisión a otro proveedor. En el caso de una emergencia relacionada con salud mental o drogadicción, diríjase directamente a la sala de emergencia de un hospital para ser evaluado/a y recibir la atención y el tratamiento adecuados.

Servicios Educativos Locales o Regionales Medicaid podría cubrir los siguientes servicios provistos por agencias educativas locales o regionales:

♦ ♦ ♦ ♦ ♦ ♦

Fisioterapia Terapia ocupacional Terapia del habla y el lenguaje Servicios de salud mental Servicios para la audición Servicios de enfermería

Servicios Médicos Administrados Si usted es miembro de Iowa Medicaid y vive en un condado donde hay Servicios Médicos Administrados (Managed Health Care), se le podría exigir que se inscriba en un plan. No perdería los beneficios de Medicaid. Podría elegir entre una organización administradora de servicios médicos (HMO) o un médico de MediPASS. IME le asignará un proveedor si no lo elige. Con los servicios médicos administrados:

♦ Tiene un médico de atención primaria. ♦ Construye la relación médico-paciente. ♦ Cuando necesita servicios médicos, tiene un número telefónico adonde llamar y un médico y personal que le conocen. ♦ Recibe la atención médica que necesita de su propio doctor y no el trato impersonal de una sala de emergencias o de un médico desconocido. ♦ Es más fácil para usted y sus hijos recibir servicios preventivos para mantenerse sanos, cosas como las vacunas para sus hijos y un PAP anual y un examen pélvico para las mujeres. Comm. 20(S) (Rev. 1/12) Página 20

Algunos servicios son diferentes a través de los Servicios Médicos Administrados, así que lea sobre sus opciones y cómo obtener servicios de Medicaid a través de Servicios Médicos Administrados. Recibirá más información una vez que haya elegido (o que sea asignado/a si no elige).

 Llame a Servicios para Miembros los días hábiles de 8:00 a.m. a 5:00 p.m. al teléfono 1-800-338-8366, o al 1-515-256-4606 en el área de Des Moines. Además, puede llamar si tiene algún problema después de inscribirse o si desea cambiar su inscripción. Puede solicitar un cambio si no le agrada la elección que hizo o si sus circunstancias cambian (por ejemplo, si se muda o si su médico se retira).

Programa para Adultos Mayores con Todos los Servicios Incluidos (PACE) PACE les ayuda a los miembros de Medicaid a mantenerse sanos y vivir en su comunidad por tanto tiempo como sea posible. El programa PACE coordinará y brindará todos los servicios para cuidados preventivos, primarios, intensivos y a largo plazo a domicilio para adultos a partir de los 55 años.

 Comuníquese con Servicios para Miembros los días hábiles de 8:00 a.m. a 5:00 p.m. al teléfono 1-800-338-8366, o al 1-515-256-4606 en el área de Des Moines para averiguar si vive en un condado que tiene el programa PACE. El representante de Servicios para Miembros le dará la información de contacto del programa PACE.

Comm. 20(S) (Rev. 1/12)

Página 21

Iowa Department of Human Services

SUPPLEMENTAL SECURITY INCOME PAYMENT STANDARDS Individual in own home ............................................. $ 698.00 Couple in own home ................................................ 1,048.00 Individual in medical institution ................................. 30.00 Individual in household of another ............................ 465.34 Couple in household of another ............................... 698.67 Essential person increment ...................................... 350.00 MEDICAL INSTITUTION LIMITS Medicaid income cap for nursing care, hospital, MHI, ICF/MR, PMIC .......... $ 2,094.00 Minimum monthly maintenance needs allowance (MMMNA) ....................... 2,841.00 Maximum community spouse resource allowance ....................................... 113,640.00 STATE SUPPLEMENTARY ASSISTANCE STANDARDS Family-Life Home Payment to family........................... $ Personal needs allowance.............. + Payment standard .......................... $

Blind Allowance (Maximum payment $22.00) 765.00 95.00 860.00

Individual......................................... $ 720.00 Couple, one is blind ........................ 1,070.00 Couple, both are blind ..................... 1,092.00

Dependent Person (Maximum payment $357.00) Aged or disabled client and dependent relative ................................................................... $ 1,055.00 Aged or disabled client, eligible spouse, and dependent relative ......................................... 1,405.00 Blind client and dependent relative ...................................................................................... 1,077.00 Blind client, aged or disabled spouse, and dependent relative ............................................ 1,427.00 Blind client, blind spouse, and dependent relative ............................................................... 1,449.00 In-Home Health-Related Care (Maximum payment $480.55) Income limits after $65 + 1/2, unmet medical needs, and diversion for dependents: Individual in own home ....................... ($480.55 + 698 home maintenance) ....................... $ 1,178.55 Couple, one member needs care ....... ($480.55 + 1,048 home maintenance) .................... 1,528.55 Couple, both need care ...................... ($480.55 + 480.55 + 1,048 home maintenance) ..... 2,009.10 Home maintenance allowance: Individual in own home ............................................. $ 698.00 Couple in own home ................................................ 1,048.00 Each additional family member ................................ 350.00 Residential Care Flat per diem rate = $17.86. Client’s maximum income after $65 + 1/2, unmet medical needs and diversions for spouse and dependents is $648.66 ($17.86 x 31 days + $95 personal needs allowance). Maximum cost-related per diem rate = $28.92. Client’s maximum income after $65 + 1/2, unmet medical needs and diversions for spouse and dependents is $991.52 ($28.92 x 31 days + $95 personal needs allowance). RC-0018 (Rev. 1/12)

Iowa Department of Human Services

Desk Aid COVERAGE GROUP

RESOURCE LIMIT

Food Assistance

$3,250 if one or more age 60 or older or disabled $2,000 all other households

Expanded FA Cat Elig

MONTHLY INCOME LIMITS 1

Household Size 3 4

2

5

6

7

Gross

$ 1,180

$

1,594

$

2,008

$

2,422

$

2,836

$

3,249

$

3,663

Net

$

908

$

1,226

$

1,545

$

1,863

$

2,181

$

2,500

$

2,818

Max Allotment

$

200

$

367

$

526

$

668

$

793

$

952

$

1,052

None

$

1 1,453

$

2 1,962

$

Household Size 3 4 2,472 $ 2,981 $

5 3,490

$

6 4,000

7 4,509

$

For each additional household member add $499. FIP

$2,000 per applicant household $5,000 per recipient household

$2,000 per FMAP and FMAP-Related applicant household Medicaid $5,000 per recipient household

Mothers and Children (MAC) Medicaid *

$10,000 per household

Household Size 3 4

1

2

5

6

7

Test 1

$ 675.25

$1,330.15

$1,570.65

$1,824.10

$2,020.20

$2,249.60

$2,469.75

Test 2

$

365

$

719

$

849

$

986

$

1,092

$

1,216

$

1,335

Test 3

$

183

$

361

$

426

$

495

$

548

$

610

$

670

Household Size 3 4

1

2

Test 1

$ 675.25

$1,330.15

$1,570.65

Test 2

$

365

$

719

$

Test 3

$

183

$

361

$

Poverty Level 300% Preg. women/infants

1

2

$ 2,793 $ 3,783

5

6

7

$1,824.10

$2,020.20

$2,249.60

$2,469.75

849

$

986

$

1,092

$

1,216

$

1,335

426

$

495

$

548

$

610

$

670

Household Size 3 4 $ 4,773

$ 5,763

5

6

7

$ 6,753

$ 7,743

$ 8,733

$ 3,433

$ 3,872

For each additional household member add $990. 133% Children 1-18

$ 1,239 $ 1,677

$ 2,116

$ 2,555

$ 2,994

For each additional household member add $439. Medically Needy Medicaid *

$10,000 per household

$

RC-0033 (Rev. 4/12)

1 483

$

Medically Needy Income Level (MNIL) by Household Size 2 3 4 5 483 $ 566 $ 666 $ 733 $

6 816

$

7 891

Page 1 of 3

100% Poverty Level

$

1 931

$

2 1,261

$

3 1,591

4 1,921

$

$

5 2,251

$

6 2,581

$

7 2,911

$

7 8,733

For each additional household member add $330.

300% Poverty Level Medicaid for Kids with Special Needs (MKSN) SSI-Related Medicaid *

$

1 2,793

$

2 3,783

$

3 4,773

SLMB * (A Medicare Savings Program)

$6,940 for one person

$10,410 for a couple

$10,410 for a couple

Expanded SLMB * (QI-1) (A Medicare Savings Program)

$6,940 for one person

QDWP Medicaid * (A Medicare Savings Program)

$4,000 for one person

MEPD Medicaid for Employed People with Disabilities

$12,000 for one person

$10,410 for a couple

$6,000 for a couple

$13,000 for a couple

$

$

6 7,743

Household Size (couple in own home) 1 2 $ 698 $ 1,048

$3,000 for a couple $6,940 for one person

$

5 6,753

For each additional household member add $990.

$2,000 for one person

QMB * (A Medicare Savings Program)

4 5,763

Poverty Level 100%

Effective 4/1/12 Poverty Level

Household Size Individual Couple $ 931 $ 1,261

Household Size

Effective 4/1/12

Individual

Over 100% but less than 120%

Couple

Poverty Level

Income Over $

Household Size

But Less Than

931

$ 1,117

$ 1,261

$ 1,513

Income

But Less Than

Effective 4/1/12

Individual

$ 1,117

$ 1,257

120% but less than 135%

Couple

$ 1,513

$ 1,703

Poverty Level Effective 4/1/12 Net countable income is less than 250% FPL

Household Size Individual Couple

200%

$ 1,862

1

2

3

$ 2,328

$ 3,153

$ 3,978

$ 2,522

MEPD Income Limit Household Size 4 5 $ 4,803

$ 5,628

6

7

8

$ 6,453

$ 7,278

$ 8,103

* Note: Compare net countable income to the income limits.

RC-0033 (Rev. 4/12)

Page 2 of 3

Monthly Income Limits IowaCare Household Size

IowaCare 1

2

3

4

5

6

7

At or below 200% FPL

$ 1,862

$ 2,522

$ 3,182

$ 3,842

$ 4,502

$ 5,162

$ 5,822

Below 300% FPL

$ 2,793

$ 3,783

$ 4,773

$ 5,763

$ 6,753

$ 7,743

$ 8,733

Monthly Medicare Part B Premium (Effective 1-1-2012) $99.90

MEPD Premiums Effective August 1, 2011 If the gross monthly income of the person getting MEPD is:

FPL

$ 1,362 or less

At or below 150%

Above:

$

1,362 1,497 1,634 1,815 2,042 2,269 2,723 3,176 3,630 4,084 4,991 5,899 6,806 7,714 9,075 10,436 11,798 $ 13,431 and above

Above:

150% 165% 180% 200% 225% 250% 300% 350% 400% 450% 550% 650% 750% 850% 1000% 1150% 1300% 1480%

Premium Amount $

0

$

34 44 54 65 75 86 106 127 148 169 209 250 292 335 399 469 560 660

IowaCare Premiums Effective April 1, 2012 One IowaCare member and income is at or below the FPL of:

Member’s premium amount is:

Two or more members and income is at or below the FPL of:

Member’s combined premium amount is:

150% = $1,397

No cost

150% = $1,892

No cost

160% = $1,490

$51

160% = $2,018

$69

170% = $1,583 180% = $1,676

$55 $58

170% = $2,144 180% = $2,270

$73 $78

190% = $1,769

$61

190% = $2,396

$82

200% = $1,862

$65

200% = $2,522

$86

RC-0033 (Rev. 4/12)

Page 3 of 3