Iowa Medicaid Enterprise FAQ

Provider Specific FAQ

Q: We do not submit claims electronically, can we continue to print claims from our computer?
A: If the form that you are using is a standard red and white drop out form, yes, you can print from your printer. If you are using a laser printer and printing black and white forms, you will need to switch to the red and white claim form. Forms that you have created to look like a claim form cannot be accepted.
Q: Regarding the IME Contact Information list, what is the Spend Down telephone number?
A: Effective 6/30/05, you will call Provider Services and they will have Spend Down information.
Q: Regarding resubmission of claims, can we use a copy of the original claims or do we have to submit a new claim?
A: Resubmissions must be sent on an original claim form. Copies cannot be accepted. Remember to always show your original filing date.
Q: Are there instructional sheets to assist with PC-ACE PRO32 software?
A: Instructional sheets are available now on the Noridian website and will soon be available on the Provider Website.
Q: Can paper claims continue to be billed to Medicaid or is Medicaid going to require only electronic submissions?
A: Paper claim submissions will continue to be accepted by Medicaid.
Q: Will Medicaid member cards have the Member Services number printed on them?
A: Yes.
Q: Can claim status be checked on the website?
A: Yes, as of 06/30/05.  You will need to enroll with EDISS in order to use this feature.
Q: Will providers be required to move to an 835 (electronic remittance advices)?
A: No.
Q: Is there are charge for using ELVS?
A: No, the Website is free to providers.  There is also a toll-free number for long distance calls to the Voice Response version of ELVS.
Q: Can Home Health Claims be billed electronically?
A: The UB 92 itself can be submitted electronically, but the documentation required would need to be submitted on paper and then attached to the electronic claim.
Q: Can red ink be used on a 2 page EOMB?
A: Red ink or highlighters can no longer be used on any claim submission. Blue or black ink is acceptable.
Q: Will a provider be able to phone Provider Services and ask more than 5 questions?
A: Yes, but a common sense approach should be used.
Q: Will Prior Authorizations have a faster turnaround time?
A: The contractual limit is 5 days, with 10 days for those needing peer review.  This applies to PA requests that do not require additional documentation from the Provider.
Q:

Can I use the dental claim form to request a prior authorization?

A:

No. Request for Prior authorization form 470-0829 must be used for Medicaid. The form and instructions can be found in the Dental Serivces Billing and Payment provider manual, Chapter F, pages 1- 6. Claim forms submitted as prior authorization requests to the IME are scanned and electronically processed for payment. Using the dental claim form for a prior approval request will result in a denied claim.

IowaCare Customer FAQ

Q: Who's eligible?
A: Generally, eligible people have low incomes and are not eligible for regular Medicaid.
Specifically, eligible Iowans are:
  1. People ages 19 - 64 who:
    • Have adjusted income at or below 200% of the Federal Poverty Level (FPL). As of June 2005, 200% of FPL is an adjusted income of about $3,200/month for a family of four.
    • Do not have access to other health insurance.
    • Are not otherwise eligible for Medicaid (childless adults, single adults, parents of Medicaid children or hawk-i children who are over income for Medicaid).
    • Meet all other conditions of participation, including requirements to pay a premium.
  2. Women who are eligible for the Family Planning waiver may also receive benefits under IowaCare.
  3. Pregnant women and newborn infants in families with household incomes of 300% FPL or less, assuming deductions for medical bills reduce family income to 200% or less.
  4. People who do not meet the 200% FPL test but who receive State Papers services for chronic health problems.
Q: You say "adjusted" income. What does that mean?
A: The amount of income earned from a job is reduced by 20 percent when calculating household income.
Q: How is IowaCare different from the State Papers program?
A: The State Papers program is Iowa's health care program for about 5,000 people with limited income who are not eligible for Medicaid. It is being replaced by IowaCare on July 1, 2005. There is no difference in the place of service (University of Iowa Hospitals and Clinics or Broadlawns Hospital in Des Moines, depending on residence, or one of the four state mental health institutes), and there is no difference in type of services offered. The only difference comes for people who receive State Papers but whose household income exceeds 200% of federal poverty level. For those people, care will continue if services are for chronic conditions (such as regular treatment for a disease). But these people will no longer be eligible for services if their prior service was for one-time needs (a broken limb, for example).
Q: How do I get an application for IowaCare?
A: Applications will be available at any DHS office or at any of the providers (Broadlawns, University of Iowa Hospitals, and the mental health institutes). In addition, everyone now receiving State Papers assistance will receive an application in the mail. Also, the DHS is asking county general relief officials to have applications available, and to assist people in filling them out. Applications will be sent to DHS offices, where eligibility will be determined.
Q: Do I need to do another interview?
A: No. There is no requirement for an interview. The DHS will help people fill out the application if assistance is needed. Eligibility will be determined on the basis of information provided by the customer. The DHS quality control process will review a sample of cases to ensure program integrity.
Q: What if I have access to other health insurance?
A: People are not eligible for IowaCare if they have access to other insurance. There are exceptions for people who did not enroll in their health insurance because it was unaffordable, or because pre-existing conditions or exclusions applied, or because needed services are not covered by their group plans. There is also an exception for people who are enrolled in a separate group plan but who have needs that are not covered.
Q: What do I have to do to remain eligible?
A: Eligible people will receive a membership card. Eligibility is for one year. Members do not need to report income changes during that time. They do need to reapply after one year. They also need to pay premiums unless they are exempt.
Q: What about the premium?
A:
  • To receive services, IowaCare members must pay a premium. The premium is calculated on the amount of adjusted household income. The premium will be between $1-14 a month per person for people whose adjusted household income is below 100% FPL, and between $34-75 a month per person for households with adjusted income of between 100% and 200% FPL. As of June 2005, 100% FPL is $1,613/month for a family of four.
  • There will be exceptions for hardship cases.
  • The amount of any hawk-i payments will be deducted from the IowaCare premium.
Q: What services are covered?
A: Expansion population benefits include hospital, physician, limited pharmacy, and limited dental services that are provided by the expansion population provider network.
Q: Will pharmaceuticals be covered?
A: If the Medicaid-expansion provider provides medications during treatment, then pharmaceuticals will be covered. Otherwise, prescription drugs are not covered by IowaCare.
Q: Will I be reimbursed for my travel expense, or will someone take me to the hospital?
A: The expansion provider network may choose to reimburse transportation expenses.
Q: Where do I receive services?
A: Services will be received at University of Iowa Hospitals in Iowa City. An option for people in Polk County is to receive services at Broadlawns Hospital. In addition, the four state mental health institutes will provide mental health needs.
Q: Why can't I take my IowaCare card and receive services at my local hospital?
A: IowaCare services will be provided only at the above named hospitals and MHIs because of a change in funding for those institutions that made IowaCare possible. The change, approved by state leaders this spring, allows programs that were previously supported only by state or local tax dollars to be matched approximately 2:1 by federal dollars.

IowaCare DHS Field FAQ

Q: What's the application process?
A:
  • Central Office will send a letter and a copy of the application form to all recipients of State Papers. Central Office will also send a letter to all county general relief directors, explaining the new law and urging them to assist in making applications available and helping people to fill them out.
  • Applications will be accepted at DHS offices beginning July 1. Applications will be available at any of the expansion population provider network, including Broadlawns, U of I Hospitals, and the four MHIs.
  • People may apply in person and DHS will help people answer the application form, but no interview is required.
  • The IowaCare program allows for one month retroactive eligibility if the individual requests this at the time of application.
Q: What's the eligibility determination process?
A:
  • The DHS will have three days to process applications.
  • No interviews are required, and verification is not required. A sampling of applications will be reviewed to verify program integrity.
  • Each application will be screened for Medicaid eligibility.
  • If the applicant is not eligible for Medicaid, he or she is reviewed for IowaCare.
  • If they are not eligible for IowaCare because income is over 200% FPL, they will still be eligible for services if they are former State Paper recipients who received services for chronic conditions. This ensures continuity of care. Funding will come from a different federal/state source. Assuming privacy issues can be addressed, the local DHS offices will be given a listing of State Paper recipients who have been treated for chronic health problems.
  • If the applicant who does not meet the 200% test received State Papers care for non-chronic conditions, the applicant is not eligible for continued services.
Q: What if the applicant has access to other health insurance?
A: People are not eligible for IowaCare if they have access to other insurance. There are exceptions for people who did not enroll in their health insurance because it was unaffordable, or because pre-existing conditions or exclusions applied, or because needed services are not covered by their group plans. There is also an exception for people who are enrolled in a separate group plan but who have needs that are not covered.
Q: What happens when eligibility is determined?
A: The member will be mailed an IowaCare card that is similar to an insurance card. In the case of former State Papers recipients who receive care for chronic health problems, a letter declaring eligibility will be sent to either Broadlawns or University Hospitals, as determined by the member's residence.
Q: Who is eligible for IowaCare?
A:
  1. People ages 19 - 64 who:
    • Have adjusted income at or below 200% of the Federal Poverty Level (FPL).
    • Do not have access to other health insurance.
    • Are not otherwise eligible for Medicaid (childless adults, single adults, parents of Medicaid children or hawk-i children who are over income for Medicaid).
    • Meet all other conditions of participation, including requirements to pay a premium.
  2. Women who are eligible for the Family Planning waiver may also receive benefits under IowaCare.
  3. Pregnant women and newborn infants in families with household incomes of 300% FPL or less, assuming deductions for medical expenses reduce the family income to 200% or less. Pregnant women in this category are eligible for prenatal services and for delivery. The newborn is eligible for a six-week follow-up exam.
  4. People who do not meet the 200% FPL test but who receive State Papers services for chronic health problems.
Q: Is eligibility automatically redetermined for any group?
A: Yes. Members are automatically redetermined if:
  • Medicaid has been canceled, and
  • There is no other categorical eligibility for Medicaid, and
  • Income falls below the threshold for paying an IowaCare premium.
If a person is canceled from Medicaid for being over income or over resource, the automatic redetermination is to the Medically Needy program.
Q: How is the premium determined?
A:
  • The premium is calculated by the IABC system based on self-declared household income. The premium will be on a sliding scale. The premium will be between $1-14 a month per person for people whose adjusted household income is at or below 100% FPL, and between $34-75 a month per person for households with adjusted income of between 100% and 200% FPL. As of June 2005, 100% FPL is $1,613/month for a family of four.
  • There will be exceptions for hardship cases, and there will be no premium for anyone whose adjusted income is below 10% of FPL.
  • The amount of any hawk-i premium will be deducted from the IowaCare premium.
  • The notice of decision regarding premium will be system-generated.
Q: When is the premium due?
A:
  • A billing statement is sent on the first day of the month and, if the payment is not received by midmonth, a reminder will be sent.
  • The premium, or a request for a hardship exemption, is due on the last day on the month. If the last day of the month is a weekend or holiday, the payment is due on the first working day of the next month.
  • If the premium is not paid by the last day of the month, the member will be disenrolled for the following month.
  • The status is considered owed to the state.
Q: Does the local office accept payments?
A: No. If a member comes to the local office with a check, the member will be given a stamped envelop and instructed to mail the payment.
Q: Concerning household size for the pregnant women program, Medicaid counts the unborn child when determining household size. Will this policy be the practice of the IowaCare program?
A: Yes, IowaCare will include the unborn in the household size.
Q: What services are covered?
A: Expansion population benefits include hospital, physician, limited pharmacy, and limited dental services that are provided by the expansion population provider network.
Q: What if some people who live in Polk County want to receive services at U of I Hospitals in Iowa City?
A: That's possible. If you live in Polk County, you may receive services at either Broadlawns Hospital or at University Hospitals in Iowa City. People in other counties receive services at University of Iowa Hospitals and Clinics. For mental health services, members receive services at any of the four MHI's.
Q: Will pharmaceuticals be covered?
A: If the Medicaid-expansion provider provides medications during treatment, then pharmaceuticals will be covered. Otherwise, prescription drugs are not covered by IowaCare.
Q: Will members be reimbursed for travel expenses, or will someone take them to the hospital?
A: The expansion provider network may choose to reimburse transportation expenses.
Q: Is there an estimate of first-year participants in IowaCare?
A: The current projection for IowaCare for the first year is between 14,000-30,000.

IowaCare County General Relief Directors FAQ

Q: What does the DHS expect General Relief directors to do?
A: General Relief directors have a long history of helping needy people within their counties. DHS would like to build on that history by asking them to help residents access IowaCare by distributing applications and helping individuals access DHS offices. While we have tried to keep the application process simple, it's likely that some people would also appreciate assistance in completing the application. General Relief directors will not be determining IowaCare eligibility.
Q: Are General Relief directors required to establish contracts with the DHS?
A: No. The legislation directs the DHS to enter into a contract with General Relief directors at their request. The DHS does not believe that a contract is necessary to allow GR directors to distribute applications and refer individuals to DHS offices.
Q: What's the application process?
A:
  • DHS Central Office will send a letter and a copy of the application form to all recipients of State Papers. Central Office will also send a letter to all county general relief directors, explaining the new law and urging them to assist in making applications available and helping people to fill them out.
  • Applications will be accepted at DHS offices beginning July 1. Applications will be available at any of the expansion population provider network, including Broadlawns, U of I Hospitals, and the four MHIs.
  • People may apply in person and DHS will help people answer the application form, but no interview is required.
  • The IowaCare program allows for one month retroactive eligibility if the individual requests this at the time of application.
    Q: How is the IowaCares program different from State Papers?
    A: There are a couple of differences. First, some counties required State Papers recipients to "spend down" or incur a minimum amount of medical expenses before they are provided papers to be seen at the University of Iowa Hospitals and Clinics. Under the IowaCare program, this is not a requirement except for the 300% OB and newborn group. Generally, individuals will be eligible for IowaCare based on their income level as it relates to the Federal Poverty Level. Most of them will also pay a premium based on income.

    The second difference is that not all State Papers recipients will receive IowaCare. Note the eligibility section below:
    • Everyone receiving State Papers benefits who have incomes below 200 percent of poverty will remain eligible.
    • If they are not eligible for IowaCare because income is over 200% FPL, they will still be eligible for services if they are former State Paper recipients who received services for chronic conditions, thus ensuring continuity of care. Funding will come from a different federal/state source. Assuming privacy issues can be addressed, the local DHS offices will be given a listing of State Paper recipients who have been treated for chronic health problems.
    • If the applicant received State Papers care for non-chronic conditions, the applicant is not eligible for continued services.
    Finally, a major change in IowaCare from the State Papers Program is that Iowa will be receiving federal matching funding for the IowaCare expenditures.
    Q: Will General Relief officials determine eligibility?
    A: No. They may help applicants with questions, but eventually they'll refer applicants to the DHS, which determines eligibility. The DHS will make a determination within three working days.
    Q: Who's eligible for IowaCare?
    A: Generally, eligible people have low incomes and are not eligible for regular Medicaid. Specifically:
    1. People ages 19 - 64 who:
      • Have adjusted income at or below 200% of the Federal Poverty Level (FPL).
      • Do not have access to other health insurance.
      • Are not otherwise eligible for Medicaid (childless adults, single adults, parents of Medicaid children or hawk-i children who are over income for Medicaid).
      • Meet all other conditions of participation, including requirements to pay a premium.
    2. People who are eligible for the Family Planning waiver may also receive benefits under IowaCare.
    3. Pregnant women and newborn infants in families with household incomes of 300% FPL or less, assuming deductions for medical bills reduce family income to 200% FPL or less.
    4. People who do not meet the 200% FPL test but who receive State Papers services for chronic health problems.
    Q: Where can IowaCare members receive service, and what services are provided?
    A: People living in Polk County may receive services at either Broadlawns Hospital or University Hospitals in Iowa City. Residents of other counties must receive services at University Hospitals in Iowa City. The state's four mental health institutes will offer mental health services.

    Expansion population benefits include hospital, physician, limited pharmacy, and limited dental services that are provided by the expansion population provider network.
    Q: When we advise potential customers, what do we say about the premium?
    A:
    • To receive services, IowaCare members must pay a premium. The premium is calculated on the amount of adjusted household income. The premium will be between $1-14 a month per person for people whose adjusted household income is below 100% FPL, and between $34-75 a month per person for households with adjusted income of between 100% and 200% FPL. As of June 2005, 100% FPL is $1,613/month for a family of four.
    • There will be no premium for anyone whose adjusted income is below 10% of FPL. There will be exceptions for hardship cases.
    • The amount of any hawk-i premium will be deducted from the IowaCare premium.
    Q: Who is our DHS contact for questions?
    A: If GR Directors have questions related to the IowaCare eligibility requirements or process, they should contact their local DHS office. If GR Directors have questions related to specific services or prescriptions medications that are covered, they should contact Deb Johnson at 515-725-1012.
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