Iowa Admin. Code r. 441-76.13 - Initial enrollment
Current through Register Vol. 44, No. 20, April 6, 2022
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441—76.13(249A) Initial enrollment.
76.13(1) Enrollment date. Applicants who have been determined to be eligible shall be enrolled by the department in the Medicaid program.
a. First day of the month. The effective date of enrollment is the first day of the first month for which eligibility has been determined, with the following exceptions:
(1)Presumptive eligibility is effective on the date that presumptive eligibility was determined by a qualified entity for presumptive Medicaid eligibility determinations.
(2)Eligibility under the qualified Medicare beneficiary coverage group begins on the first day of the month after the month of decision.
(3)Eligibility for individuals approved for supplemental security income, programs related to supplemental security income, state supplementary assistance, or medical assistance benefits shall be effective on the first day of the month when the individual was resource-eligible as of the first moment of the first day of the month and met all other eligibility criteria at any time during the month.
(4)When a request is made to add a new person to the eligible group, medical assistance shall not be effective before the first of the month in which the request was made.
(5)When a request is made prior to January 1, 2014, to add to the eligible group a person who previously was excluded, in accordance with the provisions of rule 441—75.59(249A), medical assistance for the person shall be effective no earlier than the first day of the month following the month in which the request was made.
b. Care or services prior to enrollment. No payment shall be made for medical care or services received prior to the effective date of enrollment.
76.13(2) Certification for services. The department shall issue a Medical Assistance Eligibility Card, Form 470-1911, to persons who have been determined to be eligible for the benefits provided under the Medicaid program, with the following exceptions:
a. Presumptive eligibility. A person who has been determined only presumptively eligible will be issued a Presumptive Medicaid Eligibility Notice of Action, Form 470-2580 or 470-2580(S), which will include certification information.
b. Emergency Medicaid for aliens. An individual who is eligible only for limited emergency Medicaid for aliens pursuant to 441—subrule 75.11(4) will be issued a Notice of Action, Form 470-0485 or Form 470-0485(S), which will include certification information.
76.13(3) Retroactive enrollment.
a. Except as provided in paragraph 76.13(3)“e,” medical assistance shall be available for all or any of the three months preceding the month in which an application is filed to a person who was pregnant, an infant (under the age of one), or a resident of a nursing facility licensed under Iowa Code chapter 135C during any of the three months and who:
(1)Has medical bills for covered care or services received during the three-month retroactive period; and
(2)Would have been eligible for medical assistance in the month services were received if the application for medical assistance had been made in that month.
b. The applicant need not be eligible in the month of application to be eligible in any of the three months prior to the month of application.
c. Retroactive medical assistance shall be made available when an application has been made on behalf of a deceased person who was an infant, pregnant, or a resident of a nursing facility licensed under Iowa Code chapter 135C if the conditions in paragraph 76.13(3)“a” are met.
d. Persons enrolled in Medicaid based on receipt of supplemental security income benefits who wish to make application for Medicaid benefits for the three months preceding the month of application shall complete SSI Medicaid Information, Form 470-0364, 470-0364(S), 470-0364(M), or 470-0364(MS).
e. Exceptions to retroactive enrollment. This subrule does not apply to the following persons who are otherwise eligible for retroactive enrollment:
(1)Persons whose citizenship or alien status has not been verified even though they are eligible during a 90-day reasonable opportunity period.
(2)Persons determined eligible only under presumptive Medicaid benefits.
(3)Persons eligible for Medicaid only under the qualified Medicare beneficiary program.
(4)Persons eligible only under the home- and community-based waiver services program.
[ARC 1069C, IAB 10/2/13, effective 10/1/13; ARC 3353C, IAB 10/11/17, effective 10/1/17; ARC 3549C, IAB 1/3/18, effective 2/7/18; ARC 4208C, IAB 1/2/19, effective 2/6/19]