249A.3 - ELIGIBILITY.
249A.3 ELIGIBILITY.
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. 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:
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 Budget Reconciliation Act of 1989,
Pub. L. No. 101-239, § 6401, 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.
(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. Is a woman who, while pregnant, meets eligibility
requirements for assistance under the federal Social Security Act,
section 1902(l), and continues to meet the requirements except for
income. The woman is eligible to receive assistance until sixty days
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 income is not more than two hundred
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.
(2) Additionally, effective July 1, 2009, medical assistance
shall be provided to a pregnant woman or infant whose family income
is at or below three 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, 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. Is an individual whose spouse is deceased and who is
ineligible for federal supplemental 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 federal
supplemental security income or state supplementary assistance, as
defined by section 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 earned income. The department shall
provide transitional medical assistance to the individual 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 assistance to the
individual for the maximum period allowed for federal financial
participation under federal law.
u. As allowed under the federal Deficit Reduction Act of
2005, Pub. L. No. 109-171, section 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.
2. a. 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) 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 medical assistance or additional 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 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. 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.
(2) (a) As provided under the federal Breast and Cervical Cancer
Prevention and Treatment Act of 2000, Pub. L. No. 106-354, women 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 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. A woman is
considered screened for breast and cervical cancer under this
subparagraph subdivision if the woman 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 but is not limited to breast or cervical cancer
screenings or related diagnostic services provided by family planning
or community health centers and breast cancer screenings funded by
the Susan G. Komen foundation which are provided to women 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) A woman 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 therefor, but
whose income is not in excess of the maximum established by
subsection 4 for eligibility for 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 under twenty-one years of age and whose
income and resources are such that they are eligible 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 or other persons whose needs are
considered in computing the recipient's assistance grant.
(8) Individuals under twenty-one years of age who qualify on a
financial basis for, but who are otherwise ineligible to receive
assistance under the family investment program.
(9) As allowed under 42 U.S.C. § 1396a(a)(10)(A)(ii)(XVII),
individuals under twenty-one years of age who were in foster care
under the responsibility of the state on the individual's eighteenth
birthday, and whose income is less than two hundred percent of the
most recently revised official poverty guidelines published by the
United States department of health and human services. Medical
assistance may be provided for an individual described by this
subparagraph regardless of the individual's resources.
(10) Women eligible for family planning services under a
federally approved demonstration waiver.
(11) 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.
(12) 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
medical assistance, the department may determine within the
priorities listed in this subsection which persons shall receive
medical assistance based on income levels established by the
department, subject to the limitations provided in subsection 4.
3. Additional 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:
a. Only those individuals and families described in
subsection 1 of this section; or
b. Those individuals and families described in both
subsections 1 and 2.
4. Discretionary medical assistance, within the limits of
available funds and in accordance 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. A qualified Medicare beneficiary as defined under Tit. XIX
of the federal Social Security 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 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. Beginning October 1, 1990, in determining the eligibility of
an institutionalized individual for assistance under this chapter,
the department shall establish a minimum community spouse resource
allowance amount of twenty-four thousand dollars to be retained for
the benefit of the institutionalized individual's community spouse in
accordance with the federal Social Security Act, section 1924(f) as
codified in 42 U.S.C. § 1396r-5(f).
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).
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,
division 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
1986, 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 review of eligibility under the medical
assistance program, with the exception of the following 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.
e. A child who is incarcerated in a jail or other
correctional institution. Section History: Early Form
[C62, 66, § 249A.3, 249A.4; C71, 73, 75, 77, 79, 81, § 249A.3; 81
Acts, ch 7, § 15, ch 82, § 1] Section History: Recent Form
84 Acts, ch 1297, § 3--5; 85 Acts, ch 146, § 2; 89 Acts, ch 104, §
2--4; 89 Acts, ch 304, § 202; 90 Acts, ch 1258, § 6; 90 Acts, ch
1270, § 48; 91 Acts, ch 158, § 3, 4; 92 Acts, ch 1043, § 4; 92 Acts,
2nd Ex, ch 1001, § 420; 93 Acts, ch 97, §37; 94 Acts, ch 1120, §1, 8,
9, 16; 95 Acts, ch 68, § 1; 96 Acts, ch 1129, § 64; 97 Acts, ch 41,
§26--28; 98 Acts, ch 1218, §77; 99 Acts, ch 94, §1; 99 Acts, ch 203,
§50; 99 Acts, ch 208, §50; 2000 Acts, ch 1060, §1--3; 2000 Acts, ch
1221, §6; 2000 Acts, ch 1228, §41; 2001 Acts, ch 184, §9; 2003 Acts,
ch 62, § 2; 2004 Acts, ch 1015, §1; 2005 Acts, ch 38, §1, 55; 2006
Acts, ch 1104, §1; 2006 Acts, ch 1159, §4, 8; 2007 Acts, ch 218,
§41--43, 124, 126; 2008 Acts, ch 1014, §1; 2008 Acts, ch 1188, §2, 3,
55; 2009 Acts, ch 41, §242; 2009 Acts, ch 118, §16; 2009 Acts, ch
182, §132, 134
Referred to in § 249H.3, 249J.11, 249J.13
Spousal support debt for medical assistance to institutionalized
spouse; community spouse resource allowance; chapter 249B Footnotes
2009 amendment to subsection 14 by 2009 Acts, ch 182, §132, takes
effect May 26, 2009, and applies retroactively to July 1, 2008; 2009
Acts, ch 182, §134