Iowa Admin. Code r. 441-75.4 - Medical assistance lien
(1)
When the medical assistance program pays for a member 's medical care or
expenses, the department shall have a lien upon all monetary claims which the
member may have against third parties for those expenses. Monetary claims shall
include medical malpractice claims for injuries sustained on or after July 1,
2011. The lien shall be to the extent of the medical assistance payments only.
a. A lien is not effective unless the
department files a notice of lien with the clerk of the district court in the
county where the member resides and with the member 's attorney when the
member 's eligibility for medical assistance is established. The notice of lien
shall be filed before the third party has concluded a final settlement with the
member , the member 's attorney, or other representative.
b. The third party shall obtain a written
determination from the department concerning the amount of the lien before a
settlement is deemed final.
(1) A compromise,
including, but not limited to, notification, settlement, waiver or release of a
claim, does not defeat the department 's lien except pursuant to the written
agreement of the director or the director's designee under which the department
would receive less than full reimbursement of the amounts it
expended.
(2) A settlement, award,
or judgment structured in any manner not to include medical expenses or an
action brought by a member or on behalf of a member which fails to state a
claim for recovery of medical expenses does not defeat the department 's lien if
there is any recovery on the member 's claim.
c. All notifications to the department
required by law shall be directed to the Iowa Medicaid Enterprise, Revenue
Collection Unit, P.O. Box 36475, Des Moines, Iowa 50315. Notification shall be
considered made as of the time the notification is deposited so addressed,
postage prepaid, in the United States Postal Service system.
(2) The department may pursue its
rights to recover either directly from any third party or from any recovery
obtained by or on behalf of any member . If a member incurs the obligation to
pay attorney fees and court costs for the purpose of enforcing a monetary claim
to which the department has a lien under this section, upon the receipt of the
judgment or settlement of the total claim, of which the lien for medical
assistance payments is a part, the court costs and reasonable attorney fees
shall first be deducted from this total judgment or settlement. One-third of
the remaining balance shall then be deducted and paid to the member From the
remaining balance, the lien of the department shall be paid. Any amount
remaining shall be paid to the member An attorney acting on behalf of a member
for the purpose of enforcing a claim to which the department has a lien shall
not collect from the member any amount as attorney fees which is in excess of
the amount which the attorney customarily would collect on claims not subject
to this rule. The department will provide computer-generated documents or claim
forms describing the services for which it has paid upon request of any
affected member or the member 's attorney. The documents may also be provided to
a third party where necessary to establish the extent of the department 's
claim.
(3) In those cases where
appropriate notification is not given to the department or where the
department 's recovery rights are otherwise adversely affected by an action of
the member or one acting on the member 's behalf, medical assistance benefits
shall be terminated. The medical assistance benefits of a minor child or a
legally incompetent adult member shall not be terminated. Subsequent
eligibility for medical assistance benefits shall be denied until an amount
equal to the unrecovered claim has been reimbursed to the department or the
individual produces documentation of incurred medical expense equal to the
amount of the unrecovered claim. The incurred medical expense shall not be paid
by the medical assistance program.
a. The
client , or one acting on the client 's behalf, shall provide information and
verification as required to establish the availability of medical or
third-party resources.
b. Rescinded
lAB 9/4/91, effective 11/1/91.
c.
The client or person acting on the client 's behalf shall complete Form
470-2826, Supplemental Insurance Questionnaire, in a timely manner at the time
of application, when any change in medical resources occurs during the
application period , and when any changes in medical resources occur after the
application is approved.
A report shall be considered timely when made within ten days from:
(1) The date that health
insurance begins, changes, or ends.
(2) The date that eligibility begins for care
through the Department of Veterans Affairs, specialized child health services.
Title XVIII of the Social Security Act (Medicare) and other
resources.
(3) The date the client ,
or one acting on the client 's behalf, files an insurance claim against an
insured third party, for the payment of medical expenses that otherwise would
be paid by Medicaid.
(4) The date
the member , or one acting on the member 's behalf, retains an attorney with the
expectation of seeking restitution for injuries from a possibly liable third
party, and the medical expenses resulting from those injuries would otherwise
be paid by Medicaid.
(5) The date
that the member , or one acting on the member 's behalf, receives a partial or
total settlement for the payment of medical expenses that would otherwise be
paid by Medicaid.
The
d. The member , or one acting on the member 's
behalf, shall complete the Priority Leads Letter, Form 470-0398, when the
department has reason to believe that the member has sustained an
accident-related injury. Failure to cooperate in completing and returning this
form, or in giving complete and accurate information, shall result in the
termination of Medicaid benefits.
e. When the recovery rights of the department
are adversely affected by the actions of a parent or payee acting on behalf of
a minor or legally incompetent adult member , the Medicaid benefits of the
parent or payee shall be terminated. When a parent or payee fails to cooperate
in completing or returning the Priority Leads Letter, Form 470-0398, or the
Supplemental Insurance Questionnaire, Form 470-2826, or fails to give complete
and accurate information concerning the accident-related injuries of a minor or
legally incompetent adult member , the department shall terminate the Medicaid
benefits of the parent or payee .
f.
The member , or one acting on the member 's behalf, shall refund to the
department from any settlement or payment received the amount of any medical
expenses paid by Medicaid. Failure of the member to do so shall result in the
termination of Medicaid benefits. In those instances where a parent or payee ,
acting on behalf of a minor or legally incompetent adult member , fails to
refund a settlement overpayment to the department , the Medicaid benefits of the
parent or payee shall be terminated.
(4) Third party and provider
responsibilities.
a. The health care services
provider shall inform the department by appropriate notation on the Health
Insurance Claim, Form CMS-1500, that other coverage exists but did not cover
the service being billed or that payment was denied.
b. The health care services provider shall
notify the department in writing by mailing copies of any billing information
sent to a member , an attorney, an insurer or other third party after a claim
has been submitted to or paid by the department .
c. An attorney representing an applicant for
medical assistance or a past or present Medicaid member on a claim to which the
department has filed a lien under this rule shall notify the department of the
claim of which the attorney has actual knowledge, before filing a claim,
commencing an action or negotiating a settlement offer Actual knowledge shall
include the notice to the attorney pursuant to subrule 75.4(1). The mailing and
deposit in a United States post office or public mailing box of the notice,
addressed to the department at its state or local office location, is adequate
legal notice of the claim.
(5) Department 's lien.
a. The department 's liens are valid and
binding on an attorney, insurer or other third party only upon notice by the
department or unless the attorney, insurer or other third party has actual
notice that the member is receiving medical assistance from the department and
only to the extent that the attorney, insurer or third party has not made
payment to the member or an assignee of the member prior to the notice.
Any information released to an attorney, insurer or other
third party, by the health care services provider, that indicates that
reimbursement from the state was contemplated or received, shall be construed
as giving the attorney, insurer or other third party actual knowledge of the
b. When the department has reason to believe
that an attorney is representing a member on a claim to which the department
filed a lien under this rule, the department shall issue notice to that
attorney of the department 's lien rights by mailing the Notice of Medical
Assistance Lien, Form 470-3030, to the attorney.
c. When the department has reason to believe
that an insurer is liable for the costs of a member 's medical expenses, the
department shall issue notice to the insurer of the department 's lien rights by
mailing the Notice of Medical Assistance Lien, Form 470-3030, to the
insurer
d. The mailing and deposit
in a United States post office or public mailing box of the notice, addressed
to the attorney or insurer, is adequate legal notice of the department 's
subrogation rights.
(6)
For purposes of this rule, the term "third party" includes an attorney,
individual, institution, corporation, or public or private agency which is or
may be liable to pay part or all of the medical costs incurred as a result of
injury, disease or disability by or on behalf of an applicant for medical
assistance or a past or present Medicaid member
(7) The department may enforce its lien by a
civil action against any liable third party. This rule is intended to implement
Iowa Code sections
249A.4,
249A.5, and
249A.6.
Notes
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