Providers, Services, and Billing

To receive health care through Medicaid, you may choose among healthcare providers that are enrolled in Iowa's Medicaid program. These are usually the same providers as those who serve patients not on Medicaid. Click on Lists of Providers to find a list of Medicaid providers in each county.

Iowa Medicaid Providers bill Medicaid for your health care services. They agree to accept Medicaid as full payment for the services they provide to Medicaid members. This means they cannot bill Members for any difference between their fee and what Medicaid covers.

Also, they are not supposed to bill members so long as:

  1. They know you have Medicaid and
  2. The service they provided is covered by Medicaid.

Transportation Resource Guide

Meal Reimbursement

(for Medicaid recipients who need to find rides to their medical practitioners)

This isn't true in one case: Under state law, you may be asked to make a small copayment for certain services. This would be like the copayment that people might make under a private insurance plan. A complete list of copayment amounts can be found in the Iowa Administrative Code, [441] 79.1(13).  Click on Iowa Medicaid Rules to locate this information.

The provider should:

  • Ask if you do have insurance.
  • Let you know if there will be a copayment for the service you receive.
  • Tell you if a service that you've asked for is not covered.
  • Let you know if they need Medicaid approval before they can provide a certain service.  This is known as getting prior approval.

Sometimes though, these things might not get discussed. Then it's a good idea for you to ask the questions yourself.

Your Responsibilities:

  1. Tell your provider you are on Medicaid and show your Medicaid card each time you visit them. Make sure their office has a record of the fact that you are on Medicaid.
  2. Most but not all of the providers in Iowa are enrolled in Iowa Medicaid.  When you make an appointment and you are going to see someone new, ask if the provider takes Iowa Medicaid. 
  3. Iowa Medicaid will make payments only to enrolled providers.  If you go to someone who's not enrolled, you could be responsible for payment.
  4. Say that you're going to receive a new type of service. Ask if it will be covered by Medicaid.  If not, find out if there are other services to meet the same need that Medicaid would cover.
  5. If you can, find out before you ask for a new or special type of treatment if it requires prior approval from Iowa Medicaid. If it does and the approval is not received, you could become responsible for payment.
  6. Find out if you will be billed for a copayment and, if so, how much your copayment will be.

If you do receive a bill and don't know why, you should talk first with the provider's office or with your HMO if you receive Managed Health Care. Ask their office staff to explain the bill and why you received it.

If you're still puzzled or don't agree with the charges after you talk with the provider or HMO, you should call the Member Services Call Center 1-800-338-8366 for long distance or 515-256-4606 if you live in the Des Moines area.

Finally, if you still believe that you should not be responsible for the bill, you may file an appeal.  Click on appeal rights to learn more about that process.

Federally Required Medical Services

What services can you receive under Medicaid?  Federal law requires that all State Medicaid programs cover certain services:

  • Inpatient and outpatient hospital services.
  • Physician services.
  • Medical and surgical dental services.
  • Nursing facility services for persons aged 21 or older.
  • Family planning services and supplies.
  • Rural Health clinic services.
  • Nurse-midwife services.
  • Early and periodic screening, diagnosis, and treatment (EPSDT) services for people under 21.

Other Medicaid Services Covered in Iowa

Each State may choose to cover other services.  Iowa Medicaid covers 23 more services than the list above for some or all Medicaid groups.

These services, which may have some limits, include:

  • Those provided by chiropractors, podiatrists, optometrists, and psychologists.
  • Physician-directed clinic services.
  • Dental services
  • Physical therapy
  • Occupational therapy
  • Therapies for Speech Hearing and Language Disorders
  • Home health therapies (physical, speech and language, occupational, and audiology)
  • Prescribed drugs
  • Dentures
  • Prosthetic devices
  • Eyeglasses
  • Mental health rehabilitation/stabilization
  • Impatient Hospital and Nursing Facility Services 65 and Older in IMD
  • Inpatient Psychiatric Services under age 21
  • Targeted and Primary Care Case Management
  • Hospice Care
  • Transportation Services
  • Nursing Facility Services under age 21
  • Critical Access Hospital

It's a good idea to check with the provider whenever you seek a new type of service that you haven't received before. Ask whether or not that service would be covered by Iowa Medicaid. 

The Iowa Plan

Mental Health and Substance Abuse Services may be provided for many Medicaid members through The Iowa Plan. This plan is operated for Medicaid by Magellan Behavioral Health Services. The Iowa Plan covers a comprehensive range of mental health and substance abuse services. Most mental health and substance abuse providers -- community mental health centers, hospitals, psychiatrists, substance abuse programs, and many others -- are part of Magellan's provider network for the Iowa Plan. Members may go directly to an Iowa Plan network provider for services; they do not need to contact Magellan first. If member needs assistance, Magellan is available 24 hours a day, 365 days a year toll free, at 1-800-317-3738. Members can get more information by calling Magellan or by going to the Magellan website: https://www.MagellanAssist.com/mem/benefits/pspdf/ia_clienthandbkrevaug03.pdf

 

 
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