Section 441.75.22. AIDS/HIV health insurance premium payment program.

For the purposes of this rule, “AIDS” and “HIV” are defined in accordance with Iowa Code section 141A.1.

         75.22(1) Conditions of eligibility. The department shall pay for the cost of continuing health insurance coverage to persons with AIDS or HIV-related illnesses when the following criteria are met:

            a.               The person with AIDS or HIV-related illness shall be the policyholder, or the spouse of the policyholder, of an individual or group health plan.

            b.               The person shall be a resident of Iowa in accordance with the provisions of rule 441—75.10(249A).

            c.               The person shall not be eligible for Medicaid. The person shall be required to apply for Medicaid benefits when it appears Medicaid eligibility may exist. Persons who are required to meet a spenddown obligation under the medically needy program, as provided in subrule 75.1(35), are not considered Medicaid-eligible for the purpose of establishing eligibility under these provisions.

When Medicaid eligibility is attained, premium payments shall be made under the provisions of rule 441—75.21(249A) if all criteria of that rule are met.

            d.               A physician’s statement shall be provided verifying the policyholder or the spouse of the policyholder suffers from AIDS or an HIV-related illness. The physician’s statement shall also verify that the policyholder or the spouse of the policyholder is or will be unable to continue employment in the person’s current position or that hours of employment will be significantly reduced due to AIDS or HIV-related illness. The Physician’s Verification of Diagnosis, Form 470-2958, shall be used to obtain this information from the physician.

            e.               Gross income shall not exceed 300 percent of the federal poverty level for a family of the same size. The gross income of all family members shall be counted using the definition of gross income under the supplemental security income (SSI) program.

            f.                Liquid resources shall not exceed $10,000 per household. The following are examples of countable resources:

             (1)             Unobligated cash.

             (2)             Bank accounts.

             (3)             Stocks, bonds, certificates of deposit, excluding Internal Revenue Service defined retirement plans.

            g.               The health insurance plan must be cost-effective based on the amount of the premium and the services covered.

         75.22(2) Application process.

            a.                Application. Persons applying for participation in this program shall complete the AIDS/HIV Health Insurance Premium Payment Application, Form 470-2953. The applicant shall be required to provide documentation of income and assets. The application shall be available from and may be filed at any county departmental office or at the Division of Medical Services, Department of Human Services, Hoover State Office Building, 1305 East Walnut, Des Moines, Iowa 50319-0114.

An application shall be considered as filed on the date an AIDS/HIV Health Insurance Premium Payment Application, Form 470-2953, containing the applicant’s name, address and signature is received and date-stamped in any county departmental office or the division of medical services.

            b.                Time limit for decision. Every reasonable effort will be made to render a decision within 30 days. Additional time for rendering a decision may be taken when, due to circumstances beyond the control of the applicant or the department, a decision regarding the applicant’s eligibility cannot be reached within 30 days (e.g., verification from a third party has not been received).

            c.                Eligible on the day of decision. No payments will be made for current or retroactive premiums if the person with AIDS or an HIV-related illness is deceased prior to a final eligibility determination being made on the application, if the insurance plan has lapsed, or if the person has otherwise lost coverage under the insurance plan.

            d.                Waiting list. After funds appropriated for this purpose are obligated, pending applications shall be denied by the division of medical services. A denial shall require a notice of decision to be mailed within ten calendar days following the determination that funds have been obligated. The notice shall state that the applicant meets eligibility requirements but no funds are available and that the applicant will be placed on the waiting list, or that the applicant does not meet eligibility requirements. Applicants not awarded funding who meet the eligibility requirements will be placed on a statewide waiting list according to the order in which the completed applications were filed. In the event that more than one application is received at one time, applicants shall be entered on the waiting list on the basis of the day of the month of the applicant’s birthday, lowest number being first on the waiting list. Any subsequent tie shall be decided by the month of birth, January being month one and the lowest number.

         75.22(3) Presumed eligibility The applicant may be presumed eligible to participate in the program for a period of two calendar months or until a decision regarding eligibility can be made, whichever is earlier. Presumed eligibility shall be granted when:

            a.               The application is accompanied by a completed Physician’s Verification of Diagnosis, Form 470-2958.

            b.               The application is accompanied by a premium statement from the insurance carrier indicating the policy will lapse before an eligibility determination can be made.

            c.               It can be reasonably anticipated that the applicant will be determined eligible from income and resource statements on the application.

         75.22(4) Family coverage. When the person is enrolled in a policy that provides health insurance coverage to other members of the family, only that portion of the premium required to maintain coverage for the policyholder or the policyholder’s spouse with AIDS or an HIV-related illness shall be paid under this rule unless modification of the policy would result in a loss of coverage for the person with AIDS or an HIV-related illness.

         75.22(5) Method of premium payment. Premiums shall be paid in accordance with the provisions of subrule 75.21(8).

         75.22(6) Effective date of premium payment. Premium payments shall be effective with the month of application or the effective date of eligibility, whichever is later.

         75.22(7) Reviews. The circumstances of persons participating in the program shall be reviewed quarterly to ensure eligibility criteria continues to be met. The AIDS/HIV Health Insurance Premium Payment Program Review, Form 470-2877, shall be completed by the recipient or someone acting on the recipient’s behalf for this purpose.

         75.22(8) Termination of assistance. Premium payments for otherwise eligible persons shall be paid under this rule until one of the following conditions is met:

            a.               The person becomes eligible for Medicaid. In which case, premium payments shall be paid in accordance with the provisions of rule 441—75.21(249A).

            b.               The insurance coverage is no longer available.

            c.               Maintaining the insurance plan is no longer considered the most cost-effective way to pay for medical services.

            d.               Funding appropriated for the program is exhausted.

            e.               The person with AIDS or an HIV-related illness dies.

            f.                The person fails to provide requested information necessary to establish continued eligibility for the program.

         75.22(9) Notices.

            a.               An adequate notice as defined in 441—subrule 7.7(1) shall be provided under the following circumstances:

             (1)             To inform the applicant of the initial decision regarding eligibility to participate in the program.

             (2)             To inform the recipient that premium payments are being discontinued under these provisions because Medicaid eligibility has been attained and premium payments will be made under the provisions of rule 441—75.21(249A).

             (3)             To inform the recipient that premium payments are being discontinued because the policy is no longer available.

             (4)             To inform the recipient that premium payments are being discontinued because funding for the program is exhausted.

             (5)             The person with AIDS or an HIV-related illness dies.

            b.               A timely and adequate notice as defined in 441—subrule 7.7(1) shall be provided to the recipient informing the recipient of a decision to discontinue payment of the health insurance premium when the recipient no longer meets the eligibility requirements of the program or fails to cooperate in providing information to establish eligibility.

         75.22(10) Confidentiality. The department shall protect the confidentiality of persons participating in the program in accordance with Iowa Code section 141A.9. When it is necessary for the department to contact a third party to obtain information in order to determine initial or ongoing eligibility, a Consent to Obtain and Release Information, Form 470-0429, shall be signed by the recipient authorizing the department to make the contact.

This rule is intended to implement Iowa Code section 249A.4.