Medicaid

Medicaid is a state program providing health care coverage to low-income people. This program is also referred to as Title XIX (19).

Eligibility for Medicaid programs is based, in part, on the amount of income received by the individual or household and by the amount of resources (or assets) owned by the individual or household. Most Iowans covered by Medicaid are enrolled in managed care as of April 1, 2016.

Eligibility Generally

There are many groups of people who are covered by the Medicaid program in Iowa. There are also different income and resource guidelines within each group. Not all the groups and eligibility criteria for each group can be included in this material. Rather, a description of some common coverage groups will be given, along with examples.

 

SSI Recipients

People who are eligible for Supplemental Security Income (SSI) are categorically eligible for Medicaid. This means that they are automatically eligible for Medicaid if they receive SSI benefits. The resource limit for this group is $2,000. 

 

Employed People with Disabilities

People up to age 65 who have a disability and are working may be eligible for Medicaid, with higher income and resource/asset limits than other Medicaid programs.

FMAP

Family Medical Assistance Program (FMAP) provides Medicaid for low-income families who have dependent children. Eligibility is also based on income of the family. The family’s resources do not affect eligibility for most children, but resources do affect the eligibility of the adults in the family.

The parents or caretakers of children who receive FMAP are most often younger individuals. However, if a relative other than a parent, such as a grandparent, is caring for the child, the grandparent may also be eligible for FMAP. If the child lives with both grandparents, only one of the grandparents would be eligible for FMAP. Eligibility of the grandparent is based upon the income and resources of the grandparents.

 

Iowa Health and Wellness Program (IHAWP)

IHAWP provides health care coverage at low or no cost to Iowans between the ages of 19 and 64. Eligibility is based on a household income that does not exceed 133% of the federal poverty level and is for those persons not otherwise eligible for Medicaid or Medicare. There is no asset or resource limit for the IHAWP program.  IHAWP does limit some of the services that would otherwise be covered by regular Medicaid. 

 

Persons in Nursing Facilities or Other Long-Term Care Facilities

People who are in nursing facilities or other long-term care facilities (or who live at home and need in-home care) may be eligible for Medicaid. The income limit for this group is considerably higher than for the other groups – 300 percent of the Supplemental Security Income (SSI) benefit amount (recalculated annually). Many people have incomes that exceed this annual amount but their incomes are less than the average cost for a resident of a nursing facility. These people may be able to become income-eligible for Medicaid by diverting their income into a Medical Assistance Income Trust, commonly known as a “Miller Trust.”

Resources (assets) for this group are limited to $2,000 for a single person or $3,000 for a couple when both spouses live in a nursing facility. Not all resources count toward this limit however. A homestead, vehicle, household goods, personal items and prepaid burial accounts are excluded.

If a Medicaid applicant is married and their spouse lives at home (a community spouse), the community spouse can have more than $2,000 in resources without disqualifying the Medicaid applicant, nursing home spouse, from being eligible for Medicaid. All non-exempt resources of a couple are considered available to pay nursing home costs, regardless of which spouse owns them. After excluding exempt resources, the Iowa Department of Health and Human Services (HHS) will assign one-half of the remaining resources to each spouse, provided the community spouse is assigned a minimum amount.  If the nursing home spouse is assigned more than $2,000 in resources, then the nursing home spouse will not be eligible for Medicaid until the value of the resources assigned to the nursing home spouse has been reduced to $2,000. If a couple has more than the minimum amount determined annually in resources, the decision regarding the assignment of resources (attribution) can be appealed on narrow grounds. An administrative law judge can set aside additional resources for the community spouse depending on the community spouse’s income and life expectancy.

 

Qualified Medicare Beneficiary (QMB)

Under this program, Medicaid pays Medicare Part A and B premiums, deductibles, and co-insurance amounts for beneficiaries whose income is below 100% of the federal poverty level and who have limited resources.

 

Specified Low-Income Medicare Program (SLMB)

This program will pay for the Part B Medicare premium for persons whose income is over 100% of the federal poverty level, but less than 120%. To qualify for Medicare Part B premium help under the SLMB program, an individual must be eligible for the QMB program in all areas except income.

 

Expanded Specified Low-Income Medicare Beneficiary (E-SLMB)

This program also pays for the Medicare Part B premium for persons whose income is at least 120% of the federal poverty level but less than 135% of the federal poverty level. To qualify for E-SLMB, an individual must be eligible for the QMB program in all areas except income.

Health Insurance Premium Payment (HIPP) Program

Under this program, the Iowa Department of Human Services pays for the cost of enrolling an eligible Medicaid recipient in a health insurance plan (premiums, copayments, coinsurance, and deductibles) when it is determined to be cost effective to do so. Cost effective means a determination has been made that a savings will accrue to the department by paying the insurance premium, cost sharing, wrap benefits (benefits provided by Medicaid but not by the insurance plan), and administrative cost. Certain types of plans are not eligible for participation in the HIPP program. Please call (888) 346-9562 or email hipp@dhs.state.ia.us for more information.

 

Medically Needy Program

Medically Needy is a program designed to provide medical coverage for individuals who either have limited income or high medical expenses that use up most of their income. The individuals eligible for this program include children under the age of twenty-one (21), pregnant women, persons who are blind, disabled or over 65, and adults who care for dependent children under age 18 (19 if still in school). These individuals are over income or over resources for SSI but may still be eligible for the Medically Needy program.

 

Transfer of Assets

Eligibility for Medicaid is based, in part, on the value of the applicant’s assets. An applicant for certain types of Medicaid cannot transfer or dispose of assets for less than their fair market value for the purpose of qualifying for medical assistance. An applicant who attempts to qualify for medical assistance by transferring assets for less than fair market value within five years before application for benefits, will not be eligible for certain benefits. In general terms, the applicant will be ineligible for benefits for the number of months equal to the total, cumulative uncompensated value of all assets transferred by the applicant divided by the statewide average monthly cost of a nursing facility to a private pay resident.

 

Recovery of Payments

Medical assistance to be paid to, or on behalf of, a recipient is recoverable upon the death of the recipient if the recipient was fifty-five years or older, or was a resident of a nursing facility, a facility for the intellectually disabled or a mental health facility, who, when they resided in these facilities was not expected to return home. The collection of the debt from the recipient’s estate will be waived if the collection would result in a reduction in the amount that a surviving spouse would receive from the estate, or a reduction that would be received by a surviving child that is under the age of twenty-one, blind or permanently and totally disabled. If the collection is waived, the amount waived will be collected from the estate of the surviving spouse or blind or disabled child. It will be collected from other children when they reach the age of twenty-one. The amount collected from the survivors or the survivors’ estate is limited to the amount the survivor received from the recipient’s estate. There are other exceptions to the recovery requirements that are too complex to enumerate here. Contact the Iowa Estate Recovery Program (515) 246-9841 or toll free (877) 463-7887.

 

Receiving Medicaid Coverage

If you are determined eligible for Medicaid by the Iowa Department of Health and Human Services (HHS), in most cases, your eligibility date will be the first day of the month that you apply. You will be given an opportunity to enroll with the managed care organization (MCO) of your choice. If you do not choose an MCO, you will be assigned to one. 

 

Where Do I Apply?

You may apply for any of the programs listed above at the Iowa Department of Health and Human Services (HHS) online at http://hhs.iowa.gov/how-to-apply or via phone at (800) 338-8366.