Medicaid Benefits: Online Database

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Products and Devices

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Long-Term Care Services

Community Based Care

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Benefits by State: Iowa (October 2008) Notes

Acute Care Services

Is the Benefit Covered?	Copayment Requirement	Prior Approval Requirement	Coverage Limitations	Reimbursement Methodology	Populations Covered

Institutional and Clinic Services
Clinic Services, by an organized facility or clinic not part of a hospital: Freestanding Ambulatory Surgery Center
Yes		Specified surgical procedures	Limited to procedures safely performed in ambulatory setting, as approved by CMS	Fee for service, with surgical procedures grouped using Medicare methodology, ancillaries paid at Medicare rates	CN & MN
Clinic Services, by an organized facility or clinic not part of a hospital: Public Health and Mental Health Clinics
Yes			Public Health Clinics must be state-approved and there are service specific limits, Day Treatment in Mental Health Clinics limited to 3-5 hours/day for 3-4 days/week based on individual treatment plans	Fee for service	CN & MN
Federally Qualified Health Center Services
Yes				Cost based payment	CN & MN
Inpatient Hospital Services, other than in an Institution for Mental Diseases
Yes		Non-emergency admissions, including dental and excluding maternity	LOS limited to 50th percentile of published guidelines for region	Prospective payment/discharge using DRG	CN & MN
Outpatient Hospital Services
Yes			Varying visit limits for cardiac rehab, behavioral health and substance abuse, eating disorder and pain management therapies	Fee for service, with surgical procedures grouped using Medicare methodology, ancillaries paid at Medicare rates	CN & MN
Rehabilitation Services: Mental Health and Substance Abuse
Yes	$2/day	Initial care plan and at least annually thereafter	Limited to services for treatment of chronic mental illness	Fee for service	CN & MN
Rural Health Clinic Services
Yes		Specified services	Services limited to those covered by Medicare	Cost based payment	CN & MN
Practitioner Services
Certified Registered Nurse Anesthetist Services
Yes		Specified services including some pain management		Fee for service at 80% of physician fee if no medical direction by anesthesiologist or at 60% if medical direction given	CN & MN
Chiropractor Services
Yes	$1/day		Limited to Medicare covered services	Fee for service	CN & MN
Dental Services
Yes	$3/day	Specified services including crowns	Exam and cleaning 2/year, frequency of x-rays vary by type, orthodontia and periodontia not covered, endodontia limited to root canals for anterior teeth with crowns if necessary	Fee for service	CN & MN
Medical and Remedial Care - Other Practitioners

Medical/Surgical Services of a Dentist
Yes	$3/day		Services limited to what a physician would provide	Fee for service	CN & MN
Nurse Midwife Services
Yes				Fee for service	CN & MN
Nurse Practitioner Services
Yes		Specified procedures		Fee for service	CN & MN
Optometrist Services
Yes	$2/day		1 refractive exam/year, visual aids covered when visual acuity criteria met and visual therapy limited to 90 days	Fee for service	CN & MN
Physician Services
Yes	$3/day, limited to office visits	Specified surgical procedures		Fee for service	CN & MN
Podiatrist Services
Yes	$1/day	Specified services	Specified services and appliances not covered	Fee for service	CN & MN
Psychologist Services
Yes	$2/day			Fee for service	CN & MN
Prescription Drugs
Prescription Drugs
Yes	$1/generic and preferred brand Rx, $2-$3/non-preferred brand Rx depending on payment	Specified drugs		AWP-12%, plus $4.26 dispensing fee	CN & MN
Physical Therapy and Other Services
Occupational Therapy Services
No
Physical Therapy Services
Yes	$1/day		Limited to services meeting Medicare standards	Fee for service	CN & MN
Services for Speech, Hearing and Language Disorders
Yes	$2/day		Limited to audiological assessment for a hearing aid	Fee for service	CN & MN
Products and Devices
Dentures
Yes		Fixed partial dentures, posterior partial dentures	1reline/year, 2 repairs/year	Fee for service	CN & MN
Eyeglasses
Yes	$2/day		1 pair eyeglasses/2 years unless specific criteria met, contact lenses for specified post-surgery conditions, special lenses covered if specified criteria met	Fee for service	CN & MN
Hearing Aids
Yes	$3/day	Hearing aids costing more than $650	1 hearing aid/4 years, follow up exam by physician required	Acquisition cost plus dispensing fee for hearing aid, other services/items paid fee for service	CN & MN
Medical Equipment and Supplies
Yes	$2/day	Specified med equipment and med supply items	Oxygen systems limited to specific medical conditions, med supplies limited to 3 month supply	Fee for service	CN & MN
Prosthetic and Orthotic Devices
Yes	$2/day			Fee for service	CN & MN
Transportation Services
Ambulance Services
Yes	$2/day for non-emergency transports			Fee for service	CN & MN
Non-Emergency Medical Transportation Services
Yes				See service-specific FN	CN & MN
Other Services
Diagnostic, Screening and Preventive Services
Yes	$1-$3 depending on service	Specified services	Limitations vary depending on service and provider	Fee for service or cost based payment	CN & MN
Early and Periodic Screening, Diagnosis and Treatment
See service-specific FN.
Extended Services for Pregnant Women

Family Planning Services
See service-specific FN.
Laboratory and X-Ray Services, outside Hospital or Clinic
Yes				Fee for service	CN & MN
Targeted Case Management
Yes		Specified services		Prospective cost based rate	CN & MN

Long-Term Care Services


Community Based Care
Home and Community Based Services Waiver
Yes	Services for the following populations: 1, 2, 4, 5 & 8 - See service-specific FN	Dependent upon the services provided	CN
Home Health Services, includes nursing services, home health aides, and medical supplies/equipment
Yes	Oxygen and related equipment covered for specified conditions	Cost based payment for most services with some paid on fee for service basis	CN & MN
Hospice Care
Yes		Prospective rates based on Medicare methodology	CN & MN
Personal Care Services
No
Private Duty Nursing Services
No
Program of All-Inclusive Care for the Elderly
Yes		Capitated payment	CN & MN
Institutional Care
Inpatient Hospital, Nursing Facility and Intermediate Care Facility Services In Institutions for Mental Diseases, age 65 and older
Yes	10 hosp leave days/hospitalization, 18 therapeutic leave days/year	Prospective cost based per diem, leave days paid at 75% of facility's rate	CN
Inpatient Psychiatric Services, under age 21
Yes	10 hosp leave days/hospitalization, 14 consecutive therapeutic leave days up to 30 days/year	Prospective cost based per diem with limits, leave days paid at facility's full rate	CN
Intermediate Care Facility Services for the Mentally Retarded
Yes	10 hosp leave days/hospitalization, 30 therapeutic leave days/year	Prospective cost based per diem with limits, leave days paid at 80% of facility's rate for facilities with more than 15 beds or at 95% if fewer beds	CN
Nursing Facility Services, other than in an Institution for Mental Diseases
Yes	10 hosp leave days/hospitalization, 18 therapeutic leave days/year	Prospective per diem based on resident acuity, leave days paid at 42% of facility's rate	CN
Religious Non-Medical Health Care Institution and Practitioner Services
No

Notes: This State has an approved Section 1115 Waiver from CMS under which it extended Medicaid eligibility to a number of previously uninsured individuals not otherwise eligible for Medicaid, The waiver program, called IowaCare, covers individuals age 19 through 64 with family income at or below 200 percent of the federal poverty level (FPL), including parents of children receiving Medicaid or SCHIP benefits. The program also covers pregnant women and their newborns with family income at or below 300 percent of the FPL if incurred medical expenses for family members reduces available income to the 200 percent level. The program covers children through age 17 diagnosed with serious emotional disabilities and meeting criteria for institutionalization but able to be cared for in the community if net family income is at or below 250 percent of the FPL. All three expansion groups receive a limited benefit package (hospital, physician and prescription drugs) and are generally required to obtain services from designated publicly funded providers. Monthly premiums up to 5 percent of income are required from the first two groups, and may be reduced through participation in approved healthy lifestyle activities. Copayments, including a prescription drug copayment ranging between $1 and $3 depending on drug cost, may be assessed for individuals in the first two groups as well. Iowa has also added the optional Medicaid buy-in group of disabled adults permissible through the Balanced Budget Act of 1997 in a program called Medicaid for Employed Persons with Disabilities. These beneficiaries are allowed to continue Medicaid coverage, and receive full benefits, if their income is at or below 250 percent of the FPL. Beneficiaries in this group with income above 150 percent of the FPL pay an income-based monthly premium. This State imposes a $1 copayment requirement on dually eligible Medicare and Medicaid beneficiaries for each date of service for which the State is asked to pay the coinsurance and/or deductible amount on a Medicare Part B benefit.