§ 249A.3 — Eligibility

Iowa § 249A.3

• Jurisdiction: Iowa
• Title VI: HUMAN SERVICES
• Ch. 249A: MEDICAL ASSISTANCE

Text

The extent of and the limitations upon eligibility for assistance under this chapter is
prescribed by this section, subject to federal requirements, and by laws appropriating funds
for assistance provided pursuant to this chapter.
1. Mandatory medical assistance shall be provided to, or on behalf of, any individual or
family residing in the state of Iowa, including those residents who are temporarily absent
from the state, who:
§249A.3, MEDICAL ASSISTANCE 4
a. Is a recipient of federal supplemental security income or who would be eligible for
federal supplemental security income if living in their own home.
b. Is an individual who is eligible for the family investment program or is an individual
who would be eligible for unborn child payments under the family investment program, as
authorized by Tit. IV-A of the federal Social Security Act, if the family investment program
provided for unborn child payments during the entire pregnancy.
c. Was a recipient of one of the previous categorical assistance programs as of December
31, 1973, and would continue to meet the eligibility requirements for one of the previous
categorical assistance programs as the requirements existed on that date.
d. Is a child up to one year of age who was born on or after October 1, 1984, to a woman
receiving medical assistance on the date of the child’s birth, who continues to be a member
of the mother’s household, and whose mother continues to receive medical assistance.
e. Is a pregnant woman whose pregnancy has been medically verified and who qualifies
under either of the following:
(1) The woman would be eligible for cash assistance under the family investment
program, if the child were born and living with the woman in the month of payment.
(2) The woman meets the income and resource requirements of the family investment
program, provided the unborn child is considered a member of the household, and the
woman’s family is treated as though deprivation exists.
f. Is a child who is less than seven years of age and who meets the income and resource
requirements of the family investment program.
g. (1) Is a child who is one through five years of age as prescribed by the federal Omnibus
BudgetReconciliationActof1989,Pub. L.No. 101-239,§6401,whoseincomeisnotmorethan
one hundred thirty-three percent of the federal poverty level as defined by the most recently
revised poverty income guidelines published by the United States department of health and
human services.
(2) Is a child who has attained six years of age but has not attained nineteen years of age,
whose income is not more than one hundred thirty-three percent of the federal poverty level,
as defined by the most recently revised poverty income guidelines published by the United
States department of health and human services.
h. Isawomanwho,whilepregnant,meetseligibilityrequirementsforassistanceunderthe
federal Social Security Act, section 1902(l), and continues to meet the requirements except
for income. The woman is eligible to receive assistance until twelve months after the date
pregnancy ends.
i. Is a pregnant woman who is determined to be presumptively eligible by a health care
provider qualified under the federal Omnibus Budget Reconciliation Act of 1986, Pub. L. No.
99-509, §9407. The woman is eligible for ambulatory prenatal care assistance until the last
day of the month following the month of the presumptive eligibility determination. If the
department receives the woman’s medical assistance application by the last day of the month
following the month of the presumptive eligibility determination, the woman is eligible for
ambulatory prenatal care assistance until the department actually determines the woman’s
eligibility or ineligibility for medical assistance. The costs of services provided during the
presumptive eligibility period shall be paid by the medical assistance program for those
persons who are determined to be ineligible through the regular eligibility determination
process.
j. Is a pregnant woman or infant less than one year of age whose income does not exceed
the federally prescribed percentage of the poverty level in accordance with the federal
Medicare Catastrophic Coverage Act of 1988, Pub. L. No. 100-360, §302.
k. Is a pregnant woman or infant whose income is more than the limit prescribed under
the federal Medicare Catastrophic Coverage Act of 1988, Pub. L. No. 100-360, §302, but not
more than two hundred percent of the federal poverty level as defined by the most recently
revised poverty income guidelines published by the United States department of health and
human services.
l. (1) Is an infant whose family income is not more than two hundred fifteen percent of
the federal poverty level, as defined by the most recently revised income guidelines published
by the United States department of health and human services.
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(2) Is a pregnant woman whose family income while pregnant is at or below two hundred
fifteen percent of the federal poverty level, as defined by the most recently revised poverty
income guidelines published by the United States department of health and human services,
if otherwise eligible.
m. Is a child for whom adoption assistance or foster care maintenance payments are paid
under Tit. IV-E of the federal Social Security Act.
n. Is an individual or family who is ineligible for the family investment program because
of requirements that do not apply under Tit. XIX of the federal Social Security Act.
o. Was a federal supplemental security income or a state supplementary assistance
recipient, as defined by section 249.1, and a recipient of federal social security benefits
at one time since August 1, 1977, and would be eligible for federal supplemental security
income or state supplementary assistance but for the increases due to the cost of living in
federal social security benefits since the last date of concurrent eligibility.
p. Isanindividualwhosespouseisdeceasedandwhoisineligibleforfederalsupplemental
security income or state supplementary assistance, as defined by section 249.1, due to the
elimination of the actuarial reduction formula for federal social security benefits under the
federal Social Security Act and subsequent cost of living increases.
q. Is an individual who is at least sixty years of age and is ineligible for federal
supplemental security income or state supplementary assistance, as defined by section
249.1, because of receipt of social security widow or widower benefits and is not eligible for
federal Medicare, part A coverage.
r. Is an individual with a disability, and is at least eighteen years of age, who receives
parental social security benefits under the federal Social Security Act and is not eligible for
federalsupplementalsecurityincomeorstatesupplementaryassistance,asdefinedbysection
249.1, because of the receipt of the social security benefits.
s. Is an individual who is no longer eligible for the family investment program due to
earnedincome. Thedepartmentshallprovidetransitionalmedicalassistancetotheindividual
for the maximum period allowed for federal financial participation under federal law.
t. Is an individual who is no longer eligible for the family investment program due to
the receipt of child or spousal support. The department shall provide transitional medical
assistancetotheindividualforthemaximumperiodallowedforfederalfinancialparticipation
under federal law.
u. As allowed under the federal Deficit Reduction Act of 2005, Pub. L. No. 109-171, §6062,
is an individual who is less than nineteen years of age who meets the federal supplemental
security income program rules for disability but whose income or resources exceed such
program rules, who is a member of a family whose income is at or below three hundred
percent of the most recently revised official poverty guidelines published by the United States
department of health and human services for the family, and whose parent complies with the
requirements relating to family coverage offered by the parent’s employer. Such assistance
shall be provided on a phased-in basis, based upon the age of the individual.
v. (1) BeginningJanuary1,2014,inaccordancewithsection1902(a)(10)(A)(i)(VIII)ofthe
federal Social Security Act, as codified in 42 U.S.C. §1396a(a)(10)(A)(i)(VIII), is an individual
who is nineteen years of age or older and under sixty-five years of age; is not pregnant; is not
entitled to or enrolled for Medicare benefits under part A, or enrolled for Medicare benefits
under part B, of Tit. XVIII of the federal Social Security Act; is not otherwise described in
section 1902(a)(10)(A)(i) of the federal Social Security Act; is not exempt pursuant to section
1902(k)(3), as codified in 42 U.S.C. §1396a(k)(3), and whose income as determined under
1902(e)(14) of the federal Social Security Act, as codified in 42 U.S.C. §1396a(e)(14), does not
exceedonehundredthirty-threepercentofthepovertylineasdefinedinsection2110(c)(5)of
the federal Social Security Act, as codified in 42 U.S.C. §1397jj(c)(5) for the applicable family
size.
(2) Notwithstanding any provision to the contrary, individuals eligible for medical
assistance under this paragraph “v” shall receive coverage for benefits pursuant to 42 U.S.C.
§1396u-7(b)(1)(B); adjusted as necessary to provide the essential health benefits as required
pursuant to section 1302 of the federal Patient Protection and Affordable Care Act, Pub. L.
No. 111-148; adjusted to provide prescription drugs and dental services consistent with the
§249A.3, MEDICAL ASSISTANCE 6
medical assistance state plan benefits package for individuals otherwise eligible under this
subsection; and adjusted to provide habilitation services consistent with the state medical
assistance program section 1915(i) waiver.
(3) (a) For individuals whose income as determined under this paragraph “v” is at or
below one hundred percent of the federal poverty level, covered benefits under subparagraph
(2) shall be administered consistent with program administration under this subsection.
(b) For individuals whose income as determined under this paragraph “v” is above one
hundred percent but not in excess of one hundred thirty-three percent of the federal poverty
level, covered benefits shall be administered through provision of premium assistance for
the purchase of covered benefits through the American health benefits exchange created
pursuant to the Affordable Care Act, as defined in section 249N.2.
w. Beginning January 1, 2014, is an individual who meets all of the following
requirements:
(1) Is under twenty-six years of age.
(2) Wasinfostercareundertheresponsibilityofthestateonthedateofattainingeighteen
years of age or such higher age to which foster care is provided.
(3) Wasenrolledinthemedicalassistanceprogramunderthischapterwhileinsuchfoster
care.
2. a. Mandatory medical assistance may also, within the limits of available funds and
in accordance with section 249A.4, subsection 1, be provided to, or on behalf of, other
individuals and families who are not excluded under subsection 5 of this section and whose
incomes and resources are insufficient to meet the cost of necessary medical care and
services in accordance with the following order of priorities:
(1) (a) As allowed under 42 U.S.C. §1396a(a)(10)(A)(ii)(XIII), individuals with
disabilities, who are less than sixty-five years of age, who are members of families whose
income is less than two hundred fifty percent of the most recently revised official poverty
guidelines published by the United States department of health and human services for the
family, who have earned income and who are eligible for mandatory medical assistance or
optional medical assistance under this section if earnings are disregarded. As allowed by 42
U.S.C. §1396a(r)(2), unearned income shall also be disregarded in determining whether an
individual is eligible for assistance under this subparagraph. For the purposes of determining
the amount of an individual’s resources under this subparagraph and as allowed by 42 U.S.C.
§1396a(r)(2), a maximum of ten thousand dollars of available resources for an individual and
twenty-one thousand dollars of available resources for a couple shall be disregarded, and
any additional resources held in a retirement account, in a medical savings account, or in any
other account approved under rules adopted by the department shall also be disregarded.
(b) Individuals eligible for assistance under this subparagraph, whose individual income
exceeds one hundred fifty percent of the official poverty guidelines published by the United
States department of health and human services for an individual, shall pay a premium.
The amount of the premium shall be based on a sliding fee schedule adopted by rule of the
department and shall be based on a percentage of the individual’s income. The maximum
premium payable by an individual whose income exceeds one hundred fifty percent of
the official poverty guidelines shall be commensurate with the cost of state employees’
group health insurance in this state. The payment to and acceptance by an automated case
management system or the department of the premium required under this subparagraph
shall not automatically confer initial or continuing program eligibility on an individual.
A premium paid to and accepted by the department’s premium payment process that is
subsequently determined to be untimely or to have been paid on behalf of an individual
ineligible for the program shall be refunded to the remitter in accordance with rules adopted
by the department. Any unpaid premium shall be a debt owed the department.
(2) (a) As provided under the federal Breast and Cervical Cancer Prevention and
Treatment Act of 2000, Pub. L. No. 106-354, individuals who meet all of the following criteria:
(i) Are not described in 42 U.S.C. §1396a(a)(10)(A)(i).
(ii) Have not attained age sixty-five.
(iii) Have been screened for breast and cervical cancer under the United States centers
for disease control and prevention breast and cervical cancer early detection program
7 MEDICAL ASSISTANCE, §249A.3
established under 42 U.S.C. §300k et seq., in accordance with the requirements of 42
U.S.C. §300n, and need treatment for breast or cervical cancer. An individual is considered
screened for breast and cervical cancer under this subparagraph subdivision if the individual
is screened by any provider or entity, and the state grantee of the United States centers for
disease control and prevention funds under Tit. XV of the federal Public Health Services Act
has elected to include screening activities by that provider or entity as screening activities
pursuant to Tit. XV of the federal Public Health Services Act. This screening includes breast
or cervical cancer screenings or related diagnostic services provided or funded by family
planning centers, community health centers, or nonprofit organizations, and the screenings
or services are provided to individuals who meet the eligibility requirements established by
the state grantee of the United States centers for disease control and prevention funds under
Tit. XV of the federal Public Health Services Act.
(iv) Are not otherwise covered under creditable coverage as defined in 42 U.S.C.
§300gg(c).
(b) An individual who meets the criteria of this subparagraph (2) shall be presumptively
eligible for medical assistance.
(3) Individuals who are receiving care in a hospital or in a basic nursing home,
intermediate nursing home, skilled nursing home or extended care facility, as defined by
section 135C.1, and who meet all eligibility requirements for federal supplemental security
income except that their income exceeds the allowable maximum for such eligibility, but
whose income is not in excess of the maximum established for eligibility for discretionary
medical assistance and is insufficient to meet the full cost of their care in the hospital or
health care facility on the basis of standards established by the department.
(4) Individuals under twenty-one years of age living in a licensed foster home, or in a
private home pursuant to a subsidized adoption arrangement, for whom the department
accepts financial responsibility in whole or in part and who are not eligible under subsection
1.
(5) Individuals who are receiving care in an institution for mental diseases, and who are
undertwenty-oneyearsofageandwhoseincomeandresourcesaresuchthattheyareeligible
for the family investment program, or who are sixty-five years of age or older and who meet
the conditions for eligibility in paragraph “a”, subparagraph (1).
(6) Individuals and families whose incomes and resources are such that they are eligible
for federal supplemental security income or the family investment program, but who are not
actually receiving such public assistance.
(7) Individuals who are receiving state supplementary assistance as defined by section
249.1.
(8) Individualsundertwenty-oneyearsofagewhoqualifyonafinancialbasisfor, butwho
are otherwise ineligible to receive assistance under the family investment program.
(9) Individuals eligible for family planning services under a federally approved
demonstration waiver.
(10) Individuals and families who would be eligible under subsection 1 or this subsection
except for excess income or resources, or a reasonable category of those individuals and
families.
(11) Individuals who have attained the age of twenty-one but have not yet attained the age
of sixty-five who qualify on a financial basis for, but who are otherwise ineligible to receive,
federal supplemental security income or assistance under the family investment program.
b. Notwithstanding the provisions of this subsection establishing priorities for individuals
and families to receive mandatory medical assistance, the department may determine
within the priorities listed in this subsection which persons shall receive mandatory medical
assistance based on income levels established by the department, subject to the limitations
provided in subsection 4.
3. Optional medical assistance may, within the limits of available funds and in accordance
with section 249A.4, subsection 1, be provided to, or on behalf of, either of the following
groups of individuals and families:
a. Only those individuals and families described in subsection 1.
b. Those individuals and families described in both subsections 1 and 2.
§249A.3, MEDICAL ASSISTANCE 8
4. Discretionarymedicalassistance, withinthelimitsofavailablefundsandinaccordance
with section 249A.4, subsection 1, may be provided to or on behalf of those individuals and
families described in subsection 2, paragraph “a”, subparagraph (11), of this section.
5. Assistance shall not be granted under this chapter to:
a. An individual or family whose income, considered to be available to the individual or
family, exceeds federally prescribed limitations.
b. An individual or family whose resources, considered to be available to the individual
or family, exceed federally prescribed limitations.
5A. In determining eligibility for children under subsection 1, paragraphs “b”, “f”, “g”, “j”,
“k”, “n”, and “s”; subsection 2, paragraph “a”, subparagraphs (3), (5), (6), (8), and (11); and
subsection 5, paragraph “b”, all resources of the family, other than monthly income, shall be
disregarded.
5B. In determining eligibility for adults under subsection 1, paragraphs “b”, “e”, “h”, “j”,
“k”, “n”, “s”, and “t”; subsection 2, paragraph “a”, subparagraphs (4), (5), (8), (11), and (12);
and subsection 5, paragraph “b”, one motor vehicle per household shall be disregarded.
6. In determining the eligibility of an individual for medical assistance under this
chapter, for resources transferred to the individual’s spouse before October 1, 1989, or
to a person other than the individual’s spouse before July 1, 1989, the department shall
include, as resources still available to the individual, those nonexempt resources or interests
in resources, owned by the individual within the preceding twenty-four months, which the
individual gave away or sold at less than fair market value for the purpose of establishing
eligibility for medical assistance under this chapter.
a. A transaction described in this subsection is presumed to have been for the purpose
of establishing eligibility for medical assistance under this chapter unless the individual
furnishes convincing evidence to establish that the transaction was exclusively for some
other purpose.
b. The value of a resource or an interest in a resource in determining eligibility under this
subsection is the fair market value of the resource or interest at the time of the transaction
less the amount of any compensation received.
c. If a transaction described in this subsection results in uncompensated value exceeding
twelve thousand dollars, the department shall provide by rule for a period of ineligibility
which exceeds twenty-four months and has a reasonable relationship to the uncompensated
value above twelve thousand dollars.
7. In determining the eligibility of an individual for medical assistance under this chapter,
the department shall consider resources transferred to the individual’s spouse on or after
October 1, 1989, or to a person other than the individual’s spouse on or after July 1, 1989,
and prior to August 11, 1993, as provided by the federal Medicare Catastrophic Coverage Act
of 1988, Pub. L. No. 100-360, §303(b), as amended by the federal Family Support Act of 1988,
Pub. L. No. 100-485, §608(d)(16)(B), (D), and the federal Omnibus Budget Reconciliation Act
of 1989, Pub. L. No. 101-239, §6411(e)(1).
8. Medicare cost sharing shall be provided in accordance with the provisions of Tit.
XIX of the federal Social Security Act, section 1902(a)(10)(E), as codified in 42 U.S.C.
§1396a(a)(10)(E), to or on behalf of an individual who is a resident of the state or a resident
who is temporarily absent from the state, and who is a member of any of the following
eligibility categories:
a. AqualifiedMedicarebeneficiaryasdefinedunderTit. XIXofthefederalSocialSecurity
Act, section 1905(p)(1), as codified in 42 U.S.C. §1396d(p)(1).
b. A qualified disabled and working person as defined under Tit. XIX of the federal Social
Security Act, section 1905(s), as codified in 42 U.S.C. §1396d(s).
c. A specified low-income Medicare beneficiary as defined under Tit. XIX of the federal
Social Security Act, section 1902(a)(10)(E)(iii), as codified in 42 U.S.C. §1396a(a)(10)(E)(iii).
d. An additional specified low-income Medicare beneficiary as described under Tit. XIX
of the federal Social Security Act, section 1902(a)(10)(E)(iv)(I), as codified in 42 U.S.C.
§1396a(a)(10)(E)(iv)(I).
e. An additional specified low-income Medicare beneficiary described under Tit. XIX
9 MEDICAL ASSISTANCE, §249A.3
of the federal Social Security Act, section 1902(a)(10)(E)(iv)(II), as codified in 42 U.S.C.
§1396a(a)(10)(E)(iv)(II).
9. In determining the eligibility of an institutionalized individual for assistance under this
chapter, the department shall establish a minimum community spouse resource allowance
in an amount which is the greater of twenty-four thousand dollars or the minimum required
as a condition of receipt of federal funding pursuant to section 1924(f)(2)(A)(i) of the federal
Social Security Act, as codified in 42 U.S.C. §1396r-5(f)(2)(A)(i)174, and as adjusted pursuant
to section 1924(g) of the federal Social Security Act as codified in 42 U.S.C. §1396r-5(g).
10. Group health plan cost sharing shall be provided as required by Tit. XIX of the federal
Social Security Act, section 1906, as codified in 42 U.S.C. §1396e.
11. a. In determining the eligibility of an individual for medical assistance, the
department shall consider transfers of assets made on or after August 11, 1993, as provided
by the federal Social Security Act, section 1917(c), as codified in 42 U.S.C. §1396p(c).
b. The department shall exercise the option provided in 42 U.S.C. §1396p(c) to
provide a period of ineligibility for medical assistance due to a transfer of assets by a
noninstitutionalized individual or the spouse of a noninstitutionalized individual. For
noninstitutionalized individuals, the number of months of ineligibility shall be equal to the
total, cumulative uncompensated value of all assets transferred by the individual or the
individual’s spouse on or after the look-back date specified in 42 U.S.C. §1396p(c)(1)(B)(i),
divided by the average monthly cost to a private patient for nursing facility services in Iowa
at the time of application. The services for which noninstitutionalized individuals shall
be made ineligible shall include any long-term care services for which medical assistance
is otherwise available. Notwithstanding section 17A.4, the department may adopt rules
providing a period of ineligibility for medical assistance due to a transfer of assets by a
noninstitutionalized individual or the spouse of a noninstitutionalized individual without
notice of opportunity for public comment, to be effective immediately upon filing under
section 17A.5, subsection 2, paragraph “b”, subparagraph (1), subparagraph division (a).
c. A disclaimer of any property, interest, or right pursuant to section 633E.5 constitutes
a transfer of assets for the purpose of determining eligibility for medical assistance in an
amount equal to the value of the property, interest, or right disclaimed.
d. Unless a surviving spouse is precluded from making an election under the terms of a
premarital agreement, the failure of a surviving spouse to take an elective share pursuant
to chapter 633, subchapter V, constitutes a transfer of assets for the purpose of determining
eligibility for medical assistance to the extent that the value received by taking an elective
share would have exceeded the value of the inheritance received under the will.
12. In determining the eligibility of an individual for medical assistance, the department
shall consider income or assets relating to trusts or similar legal instruments or devices
established on or before August 10, 1993, as available to the individual, in accordance with
the federal Comprehensive Omnibus Budget Reconciliation Act of 1985, Pub. L. No. 99-272,
§9506(a), as amended by the federal Omnibus Budget Reconciliation Act of 1986, Pub. L.
No. 99-509, §9435(c).
13. In determining the eligibility of an individual for medical assistance, the department
shall consider income or assets relating to trusts or similar legal instruments or devices
established after August 10, 1993, as available to the individual, in accordance with 42 U.S.C.
§1396p(d) and sections 633C.2 and 633C.3.
14. Once initial ongoing eligibility for medical assistance is determined for a child under
the age of nineteen, the department shall provide continuous eligibility for a period of up to
twelve months regardless of changes in family circumstances, until the child’s next annual
reviewofeligibilityunderthemedicalassistanceprogram, withtheexceptionofthefollowing
children:
a. A newborn child of a medical assistance-eligible woman.
b. A child whose eligibility was determined under the medically needy program.
c. A child who is eligible under a state-only funded program.
d. A child who is no longer an Iowa resident.
§249A.3, MEDICAL ASSISTANCE 10
e. A child who is incarcerated in a jail or other correctional institution.

Legislative History

[C62, 66, §249A.3, 249A.4; C71, 73, 75, 77, 79, 81, §249A.3; 81 Acts, ch 7, §15, ch 82, §1]