Iowa Admin. Code r. 441-74.12 - Benefits and service delivery
Covered 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.
Notes
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