Fee-for-Service

1. HEALTH INSURANCE PREMIUM PAYMENT PROGRAM (HIPP)

The HIPP program helps people get or keep health insurance through their employer by reimbursing the cost of the health insurance premium. HIPP helps by paying for the insurance premium. Please visit the HIPP web page for additional information. To qualify for HIPP:

• You or someone in your home must have Medicaid.
• You must have health insurance or be able to get it through your employer.
• The health insurance must be cost-effective.

2. MEDICARE SAVINGS PROGRAM (MSP)

Medicaid is a joint federal and state program that helps pay medical costs for individuals with limited income and resources. Individuals with Medicare Part A and/or Part B, who have limited income and resources, may get help paying for their out-of-pocket medical expenses from their State Medicaid Program. Iowa has programs that can help pay your Medicare expenses, like your premiums, deductible, and coinsurance.

Qualified Medicare Beneficiary (QMB)

Under the QMB program, Medicaid only pays Medicare premiums, deductibles, and coinsurance for persons who are qualified Medicare beneficiaries. If you have Medicare Part A and your resources and income are within QMB limits, you could be eligible as a qualified Medicare beneficiary.For additional information, pleaser read the QMB brochure.

Specified Low-Income Medicare Beneficiary (SLMB)

SLMB will only pay your Medicare Part B premium. The income limit is over 100 percent but less than 135 percent of the federal poverty level. Ask your DHS worker about SLMB. 
 

3. THREE DAY EMERGENCY

Up to 3 days of Medicaid is available to pay for the cost of emergency services for aliens who do not meet citizenship, alien status, or social security number requirements. The emergency services must be provided in a facility such as a hospital, clinic, or office that can provide the required care after the emergency medical condition has occurred.
 

4. MEDICALLY NEEDY (also known as the spenddown program)

If your income is too high for Medicaid but your medical costs are so high that is uses up most of your income, you may qualify for some payment help through the Medically Needy plan. If you qualify, you are responsible for paying some of the costs of your medical expenses. For more information regarding the Medically Needy program, please visit the Medically Needy web page.
 

5. PRESUMPTIVE ELIGIBLES (subject to change once ongoing eligibility is determined)

Presumptive eligibility (PE) provides Medicaid for a limited time while a formal Medicaid eligibility determination is being made by the Iowa Department of Human Services (DHS). The goal of the presumptive eligibility process is to offer immediate health care coverage to people likely to be Medicaid eligible, before there has been a full Medicaid determination. Please visit the Presumptive Eligibility web page for more information on this program.
 

6. PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE)

PACE is a program that blends Medicaid and Medicare funding. The PACE program must provide all Medicare and Iowa Medicaid covered services as well as other services that will improve and maintain the member’s overall health status. The focus of the PACE program is to provide needed services that will allow persons to stay in their homes and communities. Please visit the PACE web page for more information regarding this program. 
 

7. AMERICAN INDIAN OR ALASKA NATIVE PROGRAM

American Indians and Alaskan Natives may choose to enroll in the Managed Care program. If you are a member who identifies as American Indian or Alaskan Native, contact Iowa Medicaid Member Services at 1-800-338-8366 to learn about enrolling in the IA Health Link Managed Care program.

• Prescription services
• Early Periodic Screening, Diagnosis & Treatment (EPSDT) for individuals under the age of 21.

How does the smoking cessation program work?

For further information on the smoking cessation program, click here.

Programs

I received a letter saying I can sign up for the Medicare Savings Program, what is that?

If you qualify, Iowa Medicaid can help assist with paying your premiums for you Medicare Part A and/or Part B. There are two programs that qualify under the Medicare Savings Program. They are Qualified Medicare Beneficiary (QMB) and Specified Low-Income Medicare Beneficiary (SLMB). QMB will pay for your Medicare premiums, co-pays and deductibles. SLMB will only pay for your Medicare Part B Premiums. 

How do I sign up for the Medicare savings program? 

This is done through your local Department of Human Services. If you do not know how to get in contact with your local office, a list of phone numbers is available on our Member Services Contacts website. To inquire about your local DHS contact information, you may also contact Iowa Medicaid Member Services by phone or email. The phone number is 1-800-338-8366 or 515-256-4606 (when calling locally in the Des Moines area), Monday through Friday, 8 a.m. to 5 p.m. For telephone accessibility assistance if you are deaf, hard-of-hearing, deaf-blind, or have difficulty speaking call Relay Iowa TTY at 1-800-735-2942. The email address is IMEMemberServices@dhs.state.ia.us.

How do I check to see if I have met my spenddown for Iowa Medicaid? 

You may contact Iowa Medicaid Member Services by phone or email. The phone number is 1-800-338-8366 or 515-256-4606 (when calling locally in the Des Moines area), Monday through Friday, 8 a.m. to 5 p.m. For telephone accessibility assistance if you are deaf, hard-of-hearing, deaf-blind, or have difficulty speaking call Relay Iowa TTY at 1-800-735-2942. The email address is IMEMemberServices@dhs.state.ia.us.

Billing

I need copies of bills that Iowa Medicaid paid that should have been paid by another insurance, how do I get them? 

The Iowa Medicaid Member Services unit can place a claims history request for you. You may contact Iowa Medicaid Member Services by phone or email. The phone number is 1-800-338-8366 or 515-256-4606 (when calling locally in the Des Moines area), Monday through Friday, 8 a.m. to 5 p.m. For telephone accessibility assistance if you are deaf, hard-of-hearing, deaf-blind, or have difficulty speaking call Relay Iowa TTY at 1-800-735-2942. The email address is IMEMemberServices@dhs.state.ia.us.

You should receive the claims history within 5-7 business days for your request. If you need specific copies of bills you will need to contact your provider. Iowa Medicaid does not have copies of your bills. 

If you need copies of the bills due to an accident or injury caused by another party, your request will be sent on to Iowa Medicaid's Lien Recovery Department. Someone from the Lien Recovery department will contact you to gather additional information. 

I am pregnant and being charged co-pays. What should I do? 

First, make sure the provider is aware that you are pregnant. If your provider still continues to bill you for co-pays, contact Iowa Medicaid Member Services by phone or email. The phone number is 1-800-338-8366 or 515-256-4606 (when calling locally in the Des Moines area), Monday through Friday, 8 a.m. to 5 p.m. For telephone accessibility assistance if you are deaf, hard-of-hearing, deaf-blind, or have difficulty speaking call Relay Iowa TTY at 1-800-735-2942. The email address is IMEMemberServices@dhs.state.ia.us. Iowa Medicaid Member Services will then contact the provider charging you co-pays to explain that you should not be charged for any co-pays while you are pregnant. 

My child under 21 keeps being charged co-pays, what can I do? 

First, make sure your provider is aware that your child is under 21 and should not be charged for any co-pays. If this does not help, then please contact the Iowa Medicaid Member Services billing department to have a bill inquiry taken for you. This process can take up to 30 days and you will receive a response by mail advising you of the outcome. 

I am receiving a bill and I was eligible at the time of service, what do I do? 

Please contact the Iowa Medicaid Member Services billing department by phone, e-mail, or letter. The phone number is 1-800-338-8366 or 515-256-4606 (when calling locally in the Des Moines area), Monday through Friday, 8 a.m. to 5 p.m. For telephone accessibility assistance if you are deaf, hard-of-hearing, deaf-blind, or have difficulty speaking call Relay Iowa TTY at 1-800-735-2942. The email address is IMEMemberServices@dhs.state.ia.us. The address is:

Iowa Medicaid Enterprise

Member Services

PO Box 36510

Des Moines, IA 50315

Iowa Medicaid Member Services will begin a bill inquiry to research the reason you are being billed. The process can take up to 30 days and you will receive a response by mail.

How do I get reimbursed for expenses paid out of pocket?

Iowa Medicaid does not reimburse members. You will want to contact the Iowa Medicaid Member Services billing department so that the charges can be looked into. This process can take up to 30 days and you will receive a response by mail advising you of the outcome.

How do I get reimbursed for transportation expenses?

Medicaid members can have their non-emergency transportation costs reimbursed by Medicaid. Transportation reimbursement helps when you need transportation to a doctor appointment or therapy treatment. A Transportation Broker helps Iowa Medicaid provide this service. Transportation may be provided by a public transit system, a private company, a non-profit organization, a volunteer, or some other person. You must schedule all your non-emergency transportation needs with the broker before your trip to be eligible for reimbursement. Please click here for further information. Non-emergency transportation is not available to Iowa Health and Wellness Plan members.

Prior Authorization (PA)

How long does it take for a prior authorization (PA) to be approved?

PAs for prescriptions are processed within 24 hours of them being sent by your provider. If you are trying to get a PA for a medical service it could take up to 60 days. Generally, if your provider provides all information to Iowa Medicaid the timeframe is generally 10-15 business days.

I have been getting a RX for a long time without needing approval, why do I need approval now?

The Preferred Drug List for Iowa Medicaid changes every three months. Prescriptions you may have gotten in the past without a prior authorization may change,requiring you to receive a prior authorization before it can be filled.

My PA was not approved, how do I find out why?

You will want to contact your doctor that had made the prior authorization request. Your doctor may already know or has access to the department that handles PA's. Also, you will receive a denial letter in the mail explaining the reason the PA was denied which offers you the Right to Appeal.

Prescriptions

If I am eligible for both Medicare & Medicaid, why doesn't Medicaid pay for my prescriptions any longer?

Members that are eligible for both Medicare and Iowa Medicaid are required to be enrolled with a Medicare Part D plan. Your Medicare Part D plan is now responsible for your prescription drugs. Iowa Medicaid will now only cover psychotropic drugs (mental health medications) and some cold medicines. If you are having trouble getting one of your daily maintenance drugs covered you will need to contact your Medicare Part D plan for assistance.

How do I find out what medications are covered?

You may obtain this information from either your pharmacy or the provider that wrote the prescription for you.

I can't get my RX filled at the pharmacy. What should I do?

First, ask the pharmacist for the reason it cannot be filled. The pharmacist has that information immediately. If that does not work, contact the provider that wrote the prescription. The provider can contact the Pharmacy Helpdesk to find out if there are any issues in filling the prescription.

Providers

Can I see providers that are out of state?

Yes. You must first make sure that they are signed up with Iowa Medicaid. You may contact Iowa Medicaid Member Services by phone or email. The phone number is 1-800-338-8366 or 515-256-4606 (when calling locally in the Des Moines area), Monday through Friday, 8 a.m. to 5 p.m. For telephone accessibility assistance if you are deaf, hard-of-hearing, deaf-blind, or have difficulty speaking call Relay Iowa TTY at 1-800-735-2942. The email address is IMEMemberServices@dhs.state.ia.us. You may also find further information on existing Iowa Medicaid Providers on the DHS website here.

Also, even though a provider is on the list as accepting Iowa Medicaid members, you must check with them ahead of time to verify that they are accepting new Iowa Medicaid patients.

If I am out of state how do I find a provider that will accept Iowa Medicaid?

There is a list of the available out of state providers available on the HHS website, here. You may also contact Iowa Medicaid Member Services for more information. 

Iowa Medicaid Member Services (Monday to Friday from 8 a.m. to 5 p.m.)
1-800-338-8366 (Toll Free) 
515-256-4606 (Des Moines Area)
515-725-1351 (Fax)