Iowa Admin. Code r. 441-74.12
Current through Register Vol. 47, No. 11, December 11, 2024
Rule 441-74.12 - Benefits and service deliveryCovered benefits and the service delivery method shall be determined by the member's health status.
(1)Iowa wellness plan services. Members shall be enrolled in the Iowa health and wellness plan unless the member is determined by the department to be a medically exempt individual.a. Covered Iowa wellness plan services are essential health benefits; all other benefits required pursuant to 42 U.S.C. § 1396u-7(b)(1)(B), including prescription drugs; and dental services consistent with 441-Chapter 78.b. Members enrolled in the Iowa health and wellness plan shall be subject to enrollment in managed care, other than program for all-inclusive care for the elderly (PACE) programs, pursuant to 441-Chapter 73.c. Dental services shall be provided under the Iowa dental wellness plan as set forth in 441-Chapter 73 through a contract with one or more dental prepaid ambulatory health plans. The department may restrict member access to those dental prepaid ambulatory health plans with which the department contracts. The dental prepaid ambulatory health plan shall provide the member with a dental card identifying the member as eligible for dental services.(2)Medically exempt individuals. An Iowa health and wellness plan member who has been determined by the department to be a medically exempt individual shall be given the choice of the benefits and service delivery method provided by the Iowa wellness plan or receiving benefits and services pursuant to 441-Chapter 78. a. A member may attest to being a medically exempt individual by submitting a completed Form 470-5194.b. A provider with a current national provider identifier number, an employee of the department, a designee of the department of corrections, a managed care organization, or a mental health and disability services region established pursuant to Iowa Code sections 331.388 to 331.399 may refer a member for a medically exempt individual determination by submitting a completed Form 470-5198.c. Upon receipt of Form 470-5194 or 470-5198, the department shall determine whether the member qualifies as a medically exempt individual in accordance with 42 CFR 440.315 as amended to May 16, 2022.(3)Qualified employer-sponsored coverage. An individual who has access to cost-effective, employer-sponsored coverage shall be subject to enrollment in the health insurance premium payment program pursuant to 441-Chapter 75.Iowa Admin. Code r. 441-74.12
ARC 1135C, IAB 10/30/2013, effective 10/2/2013Amended by IAB October 29, 2014/Volume XXXVII, Number 9, effective 1/1/2015Amended by IAB January 6, 2016/Volume XXXVIII, Number 14, effective 1/1/2016Amended by IAB March 8, 2023/Volume XLV, Number 18, effective 5/1/2023