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«Comm. 20 (Rev. 4/16) Your Guide to Medicaid Fee-for-Service (FFS) Member Services: Toll Free: 1-800-338-8366 Local: 515-256-4606 Website: ...»

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Comm. 20 (Rev. 4/16)

Your Guide to Medicaid Fee-for-Service (FFS)

Member Services:

Toll Free: 1-800-338-8366

Local: 515-256-4606

Website: http://dhs.iowa.gov/ime/members

Email: IMEMemberServices@dhs.state.ia.us

Para solicitar este documento en español, comuníquese con Servicios para Miembros al

teléfono 1-800-338-8366 de 8 a.m. a 5 p.m., de lunes a viernes.

For telephone accessibility assistance if you are deaf, hard-of-hearing, deaf-blind, or have difficulty speaking, call Relay Iowa TTY at 1-800-735-2942.

Welcome to Iowa Medicaid Medicaid is a health insurance program for certain groups of people based on income levels. In addition to meeting certain income levels, you need to meet specific eligibility requirements before

you can be considered for Medicaid. The following are some of these general requirements:

• A child under the age of 21

• A parent living with a child under the age of 18

• A woman who is pregnant

• A woman in need of treatment for breast or cervical cancer

• A person who is elderly (age 65 or older)

• A person who is disabled according to Social Security standards

• An adult between the ages of 19 and 64 and whose income is at or below 133 percent of the Federal Poverty Level (FPL)

• A person who is a resident of Iowa and a U.S. citizen

• Others may qualify Inside this booklet, you will find information about the three Iowa Medicaid coverage groups and corresponding programs: IA Health Link, Medicaid Fee-for-Service (FFS), and Healthy and Well Kids in Iowa (hawk-i). Please take a few minutes to review the information in this booklet

and if you have any questions, contact the Iowa Medicaid Member Services call center at:

Toll Free: 1-800-338-8366 In the Des Moines area: 515-256-4606 Fax: 515-725-1351 Email: IMEMemberServices@dhs.state.ia.us Para solicitar este documento en español, comuníquese con Servicios para Miembros al teléfono 1-800-338-8366 de 8 a.m. a 5 p.m., de lunes a viernes.

For telephone accessibility assistance if you are deaf, hard-of-hearing, deaf-blind, or have difficulty speaking, call Relay Iowa TTY at 1-800-735-2942.

Comm. 20 (Rev. 4/16) Table of Contents Member Responsibilities

Iowa Medicaid Fee-for-Service (FFS)

• Iowa Health and Wellness Plan

• Health Insurance Premium Payment Program (HIPP)

• Medicare Savings Program (MSP)

• Three Day Emergency

• Medically Needy (also known as the spenddown program)

• Presumptive Eligibility

• Retroactive Eligibility for Previous Months

• American Indian or Alaskan Native

• Program of All-Inclusive Care for the Elderly (PACE) Program

IA Health Link Managed Care Program

• Iowa Health and Wellness Plan

• Long Term Care (LTC) Services

• Home- and Community-Based Services (HCBS) Waivers

• Intermediate Care Facilities for Persons with Intellectual Disabilities

• Residential Care Facilities

• Nursing Facilities and Skilled Nursing Facilities

• Medicaid for Employed People with Disabilities (MEPD)

• Medicare Assistance (Dual Eligibility)

• Iowa Family Planning Network (IFPN)

Healthy and Well Kids in Iowa (hawk-i)

Basic Medicaid Fee-for-Service (FFS) Information

• Limits to Medicaid-Covered Services

• Iowa Medicaid Benefits Packages

• Ambulance

• Ambulatory Surgical Center

• Appeals Process

• Behavioral Health

• Birth Control and Family Planning Clinics

• Card (Iowa Medicaid Eligibility Card)

• Case Management (Targeted)

• Children’s Services

Comm. 20 (Rev. 4/16) Page 1

• Chiropractic Services

• Clinics

• Community Mental Health Centers

• Copayments

• Dental Services

• Doctor Visits

• Emergency (ER) and Urgent Care

• Estate Recovery

• Eye Exams and Eyeglasses

• Federally Qualified Health Center

• Health Home for Members with Chronic Conditions

• Hearing Services

• Home Health Care

• Hospice Care

• Hospitalization

• Integrated Health Home for Members with Chronic Conditions

• Lab and X-ray

• Maternity Care and Birth Center Services

• Medical Equipment and Supplies

• Member Services Call Center

• Mental Health and Substance Use Disorder Services (Psychologists and Social Workers)....... 26

• Midwife Services

• Nursing Home Services

• Nurse Anesthetists and Nurse Practitioners

• Podiatry and Orthopedic Shoes

• Prescriptions and Over-the-Counter Drugs

• Providers (Who can Provide Services to Iowa Medicaid Members)

• Rural Health Clinics





• Therapy Services (Occupational, Physical, and Speech)

• Tobacco Cessation (Help to Quit Smoking)

• Transportation Services

Important Contact Information

–  –  –

As a Medicaid Fee-for-Service (FFS) member, it is your responsibility to:

• Be knowledgeable about your medical coverage.

• Keep all appointments you make with providers or call to cancel or reschedule. Some providers may stop seeing you if you miss one or more scheduled appointments.

• Ask only for medical services that are medically necessary. DHS may limit your services if you use Medicaid for services that are not necessary.

• Tell Iowa Medicaid Member Services about any changes to other health insurance coverage. Tell them if coverage ends, if you lose or get new coverage, or if you change insurance companies.

• Tell your medical providers about anyone else who may be legally responsible to pay your medical bills.

• Report to Iowa Medicaid Member Services if you are injured in an accident or if you claim medical negligence for something that required medical treatment.

• Report any settlements you get from lawsuits, insurance claims, or worker’s compensation claims. Medicaid can be denied or canceled if you don’t tell DHS about these settlements.

• Contact the Iowa Medicaid Enterprise (IME) if you were in a trauma-related incident.

Some examples of trauma include any type of unexpected accident or injury that causes harm to the individual, including but not limited to, automobile or slip and fall. You or an IME representative must give consent before any documents will be released. Call the IME Revenue Collections/Lien Recovery Unit at 1-800-543-6742 or 515-256-4620 in the Des Moines area, Monday through Friday from 8 a.m. to 5 p.m.

Comm. 20 (Rev. 4/16) Page 1 Iowa Medicaid Fee-for-Service (FFS) Some Iowa Medicaid members are served through a Fee-for-Service (FFS) system where their health care providers are paid separately for each service (like an office visit, test, or procedure).

Members who are not transitioning to the IA Health Link managed care program will remain in Medicaid FFS. This includes members who qualify for or receive services from the following FFS

programs:

• Iowa Health and Wellness Program On January 1, 2014, Medicaid began to offer a health coverage option to adults age 19-64 with income up to and including 133 percent of the Federal Poverty Level (FPL).

(A limited number of members in this program will be in the Medicaid FFS coverage program. The majority of Iowa Health and Wellness Plan members will be in the IA Health Link Program.)

• Health Insurance Premium Payment Program (HIPP)

• Medicare Savings Program (MSP)

• Qualified Medicare Beneficiary (QMB)

• Specified Low-Income Medicare Beneficiary (SLMB)

• Three Day Emergency

• Medically Needy (also known as the spenddown program)

• Presumptive Eligibility (subject to change once ongoing eligibility is determined)

• Retroactive Eligibility for Previous Months

• American Indian or Alaskan Native program American Indians and Alaskan Natives may choose to enroll in the Managed Care program. If you are a member who identifies as American Indian or Alaskan Native, contact Iowa Medicaid Member Services at 1-800-338-8366 to learn about your healthcare options.

• Program of All-Inclusive Care for the Elderly (PACE) program Please continue reading for further information on the Iowa Medicaid FFS program and if you

have any questions, contact Iowa Medicaid Member Services Call Center at:

–  –  –

Para solicitar este documento en español, comuníquese con Servicios para Miembros al teléfono 1-800-338-8366 de 8 a.m. a 5 p.m., de lunes a viernes.

For telephone accessibility assistance if you are deaf, hard-of-hearing, deaf-blind, or have difficulty speaking, call Relay Iowa TTY at 1-800-735-2942.

–  –  –

A limited number of members in this program will be in the Medicaid FFS coverage program. The majority of Iowa Health and Wellness Plan members will be in the IA Health Link Program. The Iowa Health and Wellness Plan refers to one plan that includes two separate coverage programs. All Iowa Health and Wellness Plan members are covered for the same types of health benefits but how members get medical care is different for each program. Eligibility is based on

household income. To be eligible for the Iowa Health and Wellness Plan, you must:

• Be an adult age 19 to 64

• Have an income that does not exceed 133 percent of the Federal Poverty Level o Approximately $15,521 for an individual o Approximately $20, 921 for a family of two (or higher depending on family size)

• Live in Iowa and be a U.S. citizen

• Not be otherwise eligible for Medicaid or Medicare For further information, go to: https://dhs.iowa.gov/ime/members/medicaid-a-to-z/IHAWP

Health Insurance Premium Payment Program (HIPP)

The HIPP program helps people get or keep health insurance through their employer by reimbursing the cost of the health insurance premium. HIPP helps by paying for the insurance

premium. To qualify for HIPP:

• You or someone in your home must have Medicaid.

• You must have health insurance or be able to get it through your employer.

• The health insurance must be cost-effective.

AIDS/HIV Health Insurance Premium Payment (HIPP)

The AIDS/HIV HIPP program helps people living with AIDS/HIV-related illness. It pays their health insurance premiums when they become too ill to work. To qualify for services under

the AIDS/HIV HIPP program, the person must:

• Not qualify for Medicaid

• Be a resident of Iowa

• Provide a doctor’s certification that the person cannot work because of AIDS or HIV-related illness

• Be the health insurance plan policyholder or a dependent on the spouse’s plan

• Have “liquid” assets (cash, stocks, bank accounts, etc.) less than $10,000

• Meet the income limits

–  –  –

Medicare Savings Program (MSP) Medicaid is a joint federal and state program that helps pay medical costs for individuals with limited income and resources. Individuals with Medicare Part A and/or Part B, who have limited income and resources, may get help paying for their out-of-pocket medical expenses from their State Medicaid Program. Iowa has programs that can help pay your Medicare expenses, like your premiums, deductible, and coinsurance.

Qualified Medicare Beneficiary (QMB) Under the QMB program, Medicaid only pays Medicare premiums, deductibles, and coinsurance for persons who are qualified Medicare beneficiaries. If you have Medicare Part A and your resources and income are within QMB limits, you could be eligible as a qualified Medicare beneficiary.

Specified Low-Income Medicare Beneficiary (SLMB) SLMB will only pay your Medicare Part B premium. The income limit is over 100 percent but less than 135 percent of the federal poverty level. Ask your DHS worker about SLMB.

For further information, go to: https://dhs.iowa.gov/sites/default/files/Comm060.pdf For questions regarding MSP, QMB, or SLMB, please contact your local DHS office.

Three Day Emergency Up to three days of Medicaid is available to pay for the cost of emergency services for aliens who do not meet citizenship, alien status or social security number requirements. The emergency services must be provided in a facility such as a hospital, clinic or office that can provide the required care after the emergency medical condition has occurred.

Comm. 20 (Rev. 4/16) Page 4 Medically Needy (also known as the spenddown program) If your income is too high for Medicaid but your medical costs are so high that is uses up most of your income, you may qualify for some payment help through the Medically Needy plan. If you qualify, you are responsible for paying some of the costs of your medical expenses. Medically

Needy covers:

–  –  –

Adults who care for dependent children under the age of 19 and still in school, if:

• They are the parent, aunt, uncle, grandparent or disabled stepparent of a dependent child, and

• Their income is over the income limit for Medicaid for families, or their resources (assets) are over the resource limit for Medicaid for families.



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