Iowa Admin. Code r. 441-74.1 - Definitions

Current through Register Vol. 44, No. 12, December 15, 2021

"Caretaker relative" means a relative listed in 441-subrule 75.55(1).

"Countable income" means "modified adjusted gross income" (MAGI) or "household income," as applicable, determined pursuant to 42 U.S.C. & 1396a(e)(14).

"Department" means the Iowa department of human services.

"Enrollment period" means the 12-month period for which Iowa Health and Wellness plan eligibility is established.

"Essential health benefits" means the essential health benefits defined at 42 U.S.C. § 18022.

"Federal poverty level" means the poverty income guidelines revised annually and published in the Federal Register by the U.S. Department of Health and Human Services.

"Health insurance marketplace" or "exchange" means an American health benefit exchange established pursuant to 42 U.S.C. § 18031.

"Iowa Health and Wellness Plan" means the medical assistance program set forth in this chapter.

"Iowa wellness plan" means the benefits and services provided to Iowa Health and Wellness Plan members with countable income that does not exceed 100 percent of the federal poverty level.

"Managed care organization" means an entity that (1) is under contract with the department to provide services to Medicaid recipients and (2) meets the definition of "health maintenance organization" as defined in Iowa Code section 514B.1.

"Marketplace choice plan" means the benefits and services provided to Iowa Health and Wellness Plan members with countable income between 101 percent and 133 percent of the federal poverty level.

"Medical home" means a team approach to providing health care that originates in a primary care setting; fosters a partnership among the patient, the personal provider, and other health care professionals, and where appropriate, the patient's family; utilizes the partnership to access and integrate all medical and nonmedical health-related services across all elements of the health care system and the patient's community as needed by the patient and the patient's family to achieve maximum health potential; maintains a centralized, comprehensive record of all health-related services to promote continuity of care; and has all of the following characteristics:

1. A personal provider.

2. A provider-directed team-based medical practice.

3. Whole person orientation.

4. Coordination and integration of care.

5. Quality and safety.

6. Enhanced access to health care.

7. A payment system that appropriately recognizes the added value provided to patients who have a patient-centered medical home.

"Medically exempt individual" means an individual exempt from mandatory enrollment in an alternative benefit plan pursuant to 42 CFR § 440.315 as amended on July 15, 2013.

"Member" means an individual who is receiving assistance under the Iowa Health and Wellness Plan described in this chapter.

"Minimum essential coverage" means health insurance defined in Section 5000A(f) of Subtitle D of the Internal Revenue Code.

"Modified adjusted gross income" means the financial-eligibility methodology prescribed in 42 U.S.C. § 1396a(e)(14).

"Personal provider" means the patient's first point of contact in the health care system with a primary care provider who identifies the patient's health-related needs and, working with a team of health care professionals and providers of medical and nonmedical health-related services, provides for and coordinates appropriate care to address the health-related needs identified.

"Primary care provider" includes but is not limited to any of the following licensed or certified health care professionals who provide primary care:

1. A physician who is a family or general practitioner, a pediatrician, an internist, an obstetrician, or a gynecologist.

2. An advanced registered nurse practitioner.

3. A physician assistant.

4. A chiropractor.

"Primary medical provider" means a personal provider trained to provide first contact and continuous and comprehensive care to a member, chosen by a member or to whom a member is assigned under the Iowa health and wellness plan as the member's primary medical provider.

"Qualified employer-sponsored coverage" shall be defined pursuant to 42 U.S.C. § 1396e-1(b).

"Qualified health plan" shall be defined pursuant to Section 1301 of the Patient Protection and Affordable Care Act, Public Law 111-152.


Iowa Admin. Code r. 441-74.1
ARC 1135C, IAB 10/30/2013, effective 10/2/2013 Amended by IAB October 29, 2014/Volume XXXVII, Number 9, effective 1/1/2015 Amended by IAB January 6, 2016/Volume XXXVIII, Number 14, effective 1/1/2016 Amended by IAB January 3, 2018/Volume XL, Number 14, effective 2/7/2018

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