Section 441.74.11. Financial participation.

         74.11(1) Copayment. Payment for nonemergency use of a hospital emergency department shall be subject to an $8 copayment by the member, which shall be subtracted from the Iowa Health and Wellness Plan payment otherwise due to the provider. This copayment will be waived during calendar year 2014.

         74.11(2) Monthly contributions. Members enrolled in the Iowa Health and Wellness Plan with household income at or above 50 percent of the federal poverty level are required to pay monthly contributions pursuant to this rule.

            a.                Monthly contribution amount. The monthly contribution amount for each member is based on the countable income of the member’s household, determined pursuant to rule 441—75.70(249A), as a percentage of the federal poverty level (FPL) for the household. Monthly contribution amounts are as follows:

             (1)             For a member with household income between 50 and 100 percent of the FPL, $5;

             (2)             For a member with household income above 100 percent of the FPL, $10.

            b.                Waiver during the first year of enrollment. The monthly contribution will be waived during the member’s first 12 months of continuous enrollment.

            c.                Monthly contribution exemptions. A member shall be exempt from monthly contribution payments when any of the following circumstances apply:

             (1)             The member completed healthy behaviors pursuant to subrule 74.11(4) in the previous enrollment period.

             (2)             The member is determined to be a medically exempt individual pursuant to subrule 74.12(3).

             (3)             The member has access to cost-effective, employer-sponsored coverage and is enrolled in the health insurance premium payment program pursuant to 441—Chapter 75.

             (4)             The member is exempt from premiums pursuant to 42 CFR 447.56(a)(1)(x) as an Indian who is eligible to receive or has received an item or service furnished by an Indian health care provider or through referral under contract health services.

             (5)             The member claims a hardship exemption indicating that payment of the monthly contribution will be a financial hardship. The member may claim a hardship exemption by telephoning the call center designated by the department, by checking the hardship box on the billing statement (for the month of the billing statement), or by submitting a written statement to the address designated by the department. The member’s hardship exemption must be received or postmarked within five working days after the monthly contribution due date. If the hardship exemption request is not made in a timely manner, the exemption shall not be granted.

            d.                Billing and payment. Form 470-5285, Iowa Health and Wellness Plan Billing Statement, shall be used for billing and collection.

             (1)             Method of payment. Members shall submit contribution payments to the following address: Iowa Medicaid Enterprise, Iowa Health and Wellness Plan Monthly Contributions, P.O. Box 14485, Des Moines, Iowa 50306-3485.

             (2)             Due date. When the department notifies a member of the amount of the monthly contribution, the member shall pay any monthly contributions due in accordance with the following:

            1.      The monthly contribution for each month is due on the last calendar day of the month that the monthly contribution is to cover.

            2.      If the last calendar day falls on a weekend or state or federal holiday, payment is due on the first working day following the weekend or holiday.

            3.      Monthly contribution payments must be received or postmarked by the due date.

             (3)             Application of payment. The department shall apply monthly contributions payments received to the oldest unpaid month in the current enrollment period. When monthly contributions for all months in the enrollment period have been paid, the department shall hold any excess and apply it to any months for which eligibility is subsequently established.

            e.                Failure to pay monthly contributions.

             (1)             An Iowa wellness plan member who fails to pay the assessed monthly contributions and who does not qualify for a monthly contribution exemption pursuant to subrule 74.11(2) shall owe the monthly contribution to the department as an unpaid premium subject to recovery in accordance with rule 441—75.28(249A). A member shall have no less than 90 days from the due date to pay any unpaid monthly contribution before the unpaid amount shall be subject to recovery.

             (2)             A marketplace choice plan member who fails to pay the assessed monthly contribution and who does not qualify for a monthly contribution exemption pursuant to subrule 74.11(2) shall have the member’s eligibility terminated. In addition, the unpaid monthly contribution shall be subject to recovery in accordance with rule 441—75.28(249A) as an unpaid premium.

            1.      A member shall have no less than 90 days from the due date to pay any unpaid monthly contribution before eligibility will be terminated or the unpaid amount will be subject to recovery.

            2.      A member whose eligibility is terminated due to nonpayment of monthly contributions must reenroll for Medicaid benefits pursuant to 441—Chapter 76.

            f.                 Refund of monthly contributions.

             (1)             Monthly contributions paid for any period shall be refunded if the member qualified for a monthly contribution exemption pursuant to paragraph 74.11(2)“c” or when a member’s Iowa Health and Wellness Plan coverage is terminated for the following reasons:

            1.      The member is no longer eligible for coverage in the Iowa Health and Wellness Plan; or

            2.      The member dies.

             (2)             The amount of any refund shall be offset by any outstanding monthly contributions owed.

             (3)             The refund shall be paid within two calendar months.

         74.11(3) Aggregate annual limits on copayments and monthly contributions. The total aggregate annual amount of copayments and monthly contributions for an individual shall not exceed 5 percent of the household’s countable annual income determined pursuant to rule 441—75.70(249A).

         74.11(4) Healthy behaviors. An Iowa Health and Wellness Plan member who completes a wellness examination and health risk assessment during any enrollment year shall have monthly contributions waived in the subsequent enrollment year.

            a.               Under healthy behaviors, a wellness examination may be related to either physical health or oral health. Physical examinations must be performed by a medical provider and must assess a member’s overall physical health consistent with standard clinical guidelines for preventive physical examinations and as defined by the department. Oral examinations must be performed by a dentist consistent with standard oral health guidelines for preventive dental examinations and as defined by the department.

            b.               A health risk assessment must be one of the following:

             (1)             An “Assess My Health” assessment offered through the department;

             (2)             An assessment offered by a managed care plan through which the member is receiving Iowa Health and Wellness Plan benefits; or

             (3)             An assessment offered by a qualified health plan through which the member is receiving Iowa Health and Wellness Plan benefits.

[ARC 1135C, IAB 10/30/13, effective 10/2/13; ARC 1698C, IAB 10/29/14, effective 1/1/15; ARC 2361C, IAB 1/6/16, effective 1/1/16]