A State Plan is a contract between a state and the Federal Government describing how that state administers its Medicaid program. It gives an assurance that a state abides by Federal rules and may claim Federal matching funds for its Medicaid program activities. The state plan sets out groups of individuals to be covered, services to be provided, methodologies for providers to be reimbursed and the administrative requirements that States must meet to participate. States frequently send a state plan amendment, otherwise referred to as a SPA, to the Centers for Medicare and Medicaid Services (CMS) for review and approval. There are many reasons why a state might want to amend their state plan. For example, the state may wish to implement changes required by Federal or state law, Federal or state regulations, or court orders. States also have the flexibility to request permissible program changes, make corrections, or update their plan with new information.

Send your questions or comments to:
Jennifer Steenblock - jsteenb@dhs.state.ia.us

State Plan Amendment Sections

 

Sections

Section 1 - Single State Agency Organizations

1.1       Designation and Authority
1.2       Organization for Administration
1.3       Statewide Operation
1.4       Tribal Consultation Requirements
1.5       Pediatric Immunization Program

Section 2 - Coverage and Eligibility

2.1       Application, Determination of Eligibility and Furnishing Medicaid
2.2       Coverage and Conditions of Eligibility
2.3       Residence
2.4       Blindness
2.5       Disability
2.6       Financial Eligibility
2.7       Medicaid Furnished Out of State

Section 3 - Services: General Provisions

3.1       Amount, Duration and Scope of Services
3.2       Coordination of Medicaid with Medicare and Other Insurance
3.3       Medicaid for Individuals Age 65 or Over in Institutions for Mental Diseases
3.4       Special Requirements Applicable to Sterilization Procedures
3.5       Families Receiving Extended Medicaid Benefits

Section 4 ‑ General Program Administration

4.1       Methods of Administration
4.2       Hearings for Applicants and Recipients
4.3       Safeguarding Information on Applicants and Recipients
4.4       Medicaid Quality Control
4.5       Medicaid Agency Fraud Detection and Investigation Program
4.6       Reports
4.7       Maintenance of Records
4.8       Availability of Agency Program Manuals
4.9       Reporting Provider Payments to the Internal Revenue Service
4.10     Free Choice of Providers
4.11     Relations with Standard‑Setting and Survey Agencies
4.12     Consultation to Medical Facilities
4.13     Required Provider Agreement
4.14     Utilization Control
4.15     Inspections of Care in Skilled Nursing and Intermediate Care Facilities and Institutions for Mental Diseases
4.16     Relations with State Health and Vocational Rehabilitation Agencies and Title V Grantees
4.17     Liens and Recoveries
4.18     Cost Sharing and Similar Charges
4.19     Payment for Services
4.20     Direct Payments to certain Recipients for Physicians' or Dentists' Services
4.21     Prohibition Against Reassignment of Provider Claims
4.22     Third Party Liability
4.23     Use of Contracts
4.24     Standards for Payments for Skilled Nursing and Intermediate Care Facility Services
4.25     Program for Licensing Administrators of Nursing Homes
4.26     RESERVED
4.27     Disclosure of Survey information and Provider or Contractor Evaluation
4.28     Appeals Process for Skilled Nursing and Intermediate Care Facilities
4.29     Conflict of Interest Provisions
4.30     Exclusion of Providers and Suspension of Practitioners Convicted and Other Individuals
4.31     Disclosure of Information by Providers and Fiscal Agents
4.32     Income and Eligibility Verification System
4.33     Medicaid Eligibility Cards for Homeless Individuals
4.34     Systematic Alien Verification for Entitlements
4.35     Remedies for Skilled Nursing and Intermediate Care Facilities that Do Not Meet Requirements of Participation
4.36     Required Coordination Between the Medicaid and WIC Programs
4.38     Nurse Aide Training and Competency Evaluation for Nursing Facilities
4.39     Preadmission Screening and Annual Resident Review in Nursing Facilities
4.40     Survey & Certification Process
4.41     Resident Assessment for Nursing Facilities
4.42     Determining Eligibility For Medicare Prescription Drug Low-Income Subsidies
4.43     Employee Education About False Claims Recoveries
4.44     Cooperation with Medicaid Integrity Program Efforts
4.45     Medicaid Prohibition on Payments to Institutions or Entities Located Outside of the United States
4.46     Provider Screening and Enrollment

4.5        Medicaid Recovery Audit Contractor Program

Section 5 ‑ Personnel Administration

5.1       Standards of Personnel Administration
5.2       RESERVED
5.3       Training Programs; Subprofessional and Volunteer Programs

Section 6 ‑ Financial Administration

6.1       Fiscal Policies and Accountability
6.2       Cost Allocation
6.3       State Financial Participation

Section 7 ‑ General Provisions

7.1       Plan Amendments
7.2       Nondiscrimination
7.3       Maintenance of AFDC Effort
7.4       State Governor's Review

Cost Sharing

G1      Cost Sharing Requirements
G2a    Medicaid Premiums and Cost Sharing
G2b    Cost Sharing Amounts - Medically Needy Individuals
G2c    Cost Sharing Amounts - Targeting
G3      Cost Sharing Limitations

Eligibility

Medicaid State Plan Eligibility

S10      MAGI Based Income Methodologies
S14      AFDC Income Standards
S16      Presumptive Eligibility for Children
S25      Eligibility Groups - Mandatory Coverage - Parents and Other Caretaker Relatives
S28      Eligibility Groups - Mandatory Coverage - Pregnant Women
S30      Eligibility Groups - Mandatory Coverage - Infants and Children Under Age 19
S32      Eligibility Groups - Mandatory Coverage - Adults
S33      Eligibility Groups - Mandatory Coverage - Former Foster Care Children
S50      Eligibility Groups - Options for Coverage - Individuals Above 133% Federal Poverty Level (FPL)
S51      Eligibility Groups - Options for Coverage - Coverage of Parents and Other Caretaker Relatives
S52      Eligibility Groups - Options for Coverage - Reasonable Classification of Individuals Under Age 21
S53      Eligibility Groups - Options for Coverage - Children with Non IV-E Adoption Assistance
S54      Eligibility Groups - Options for Coverage - Optional Targeted Low Income Children
S55      Eligibility Groups - Options for Coverage - Individuals with Tuberculosis
S57      Eligibility Groups - Options for Coverage - Independent Foster Care Adolescents
S59      Eligibility Groups - Options for Coverage - Individuals Eligible for Family Planning Services
S88      Non-Financial Eligibility - State Residency
S89      Non-Financial Eligibility - Citizenship and Non-Citizen Eligibility
S94      General Eligibility Requirements - Eligibility Process

 

List of Attachments

1.1-A       Attorney General's Certification
1.1-B      Waivers under the Intergovernmental Cooperation Act
1.2-A      Organization and Function of State Agency
1.2-B      Organization and Function of Medical Assistance Unit
1.2-C      Professional Medical and Supporting Staff
1.2-D      Description of Staff Making Eligibility Determination
 

2.1-A      Definition of an HMO That Is Not Federally Qualified

2.2-A      Groups Covered and Agencies Responsible for Eligibility Determination

2.6-A      Eligibility Conditions and Requirements (States only)

3.1-A     Amount, Duration, and Scope of Medical and Remedial Care and Services Provided to the Categorically Needy

3.1-B     Amount, Duration, and Scope of Services Provided to the Medically Needy Groups: Children Under 21, Pregnant Women, Caretaker Relatives and SSI-Related

3.1-C     Standards and Methods of Assuring High Quality Care

3.1-D     Methods of Providing Transportation

3.1-E     Standards for the Coverage of Organ Transplant Procedures

3.1-F      Amount, Duration and Scope of Medical and Remedial Care and Services Provided to the Categorically Needy

3.1-L      Iowa Marketplace Choice Plan

3.1-L      Iowa Wellness Plan

3.2-A       Coordination of Title XIX with Part B of Title XVIII

3.2-B       Coordination of Title XIX with Part A of Title XVIII

 

4.11-A     Standards for Institutions

4.14-A     Single Utilization Review Methods for Intermediate Care Facilities

4.14-B     Multiple Utilization Review Methods for Intermediate Care Facilities

4.16-A     Cooperative Arrangements with State Health and State Vocational Rehabilitation Agencies and with Title V Grantees

4.17-A     Determining that an Institutionalized Individual Cannot Be Discharged and Returned Home

4.18-A     Charges Imposed on Categorically Needy

4.18-B     Medically Needy-Premium

4.18-C     Charges Imposed on Medically Needy and other Optional Groups

4.18-D     Premiums Imposed on Low Income Pregnant Women and Infants

4.18-E     Premiums Imposed on Qualified Disabled and Working Individuals

4.19-A     Methods and Standards for Establishing Payment Rates - Inpatient Hospital Care

4.19-B     Methods and Standards for Establishing Payment Rates - Other Types of Care

4.19-C     Payments for Reserved Beds

4.19-D     Methods and Standards for Establishing Payment Rates - Skilled Nursing and Intermediate Care Facility Services

4.19-E     Timely-Claims Payment - Definition of Claim

4.20-A     Conditions for Direct Payment for Physicians and Dentists Services

4.22-A     Requirements for Third Party Liability - Identifying Liable Resources

4.22-B     Requirements for Third Party Liability - Payment of Claims

4.22-C     Cost-Effective Methods for Employer-Based Group Health Plans

4.30         Sanctions for Psychiatric Hospitals

4.32-A     Income and Eligibility Verification System Procedures: Requests to Other State Agencies

4.33-A     Method for Issuance of Medicaid Eligibility Cards to Homeless Individuals

4.34-A     Requirements for Advance Directives Under State Plans for Medical Assistance

4.35-A     Eligibility Conditions and Requirements: Enforcement of Compliance for Nursing Facilities

4.35-B     Eligibility Conditions and Requirements: Enforcement of Compliance for Nursing Facilities

4.35-C     Eligibility Conditions and Requirements: Enforcement of Compliance for Nursing Facilities

4.35-D     Eligibility Conditions and Requirements: Enforcement of Compliance for Nursing Facilities

4.35-E     Eligibility Conditions and Requirements: Enforcement of Compliance for Nursing Facilities

4.35-F     Eligibility Conditions and Requirements: Enforcement of Compliance for Nursing Facilities

4.35-G     Eligibility Conditions and Requirements: Enforcement of Compliance for Nursing Facilities

4.35-H     Eligibility Conditions and Requirements: Enforcement of Compliance for Nursing Facilities

4.35-I      Eligibility Conditions and Requirements: Enforcement of Compliance for Nursing Facilities

4.39-A      Preadmission Screening and Annual Resident Review in Nursing Facilities

4.40-A     Eligibility Conditions and Requirements: Survey and Certification Education Program

4.40-B     Eligibility Conditions and Requirements: Process for the Investigation of Allegations of Resident Neglect and Abuse and Misappropriation of Resident Property

4.40-C     Eligibility Conditions and Requirements: Procedures for Scheduling and Conduct of Standard Surveys

4.40-D     Eligibility Conditions and Requirements: Programs to Measure and Reduce Inconsistency

4.40-E     Eligibility Conditions and Requirements: Process for Investigations of Complaints and Monitoring

4.43-A     Frequency and Description of Method of Compliance and Oversight

7.2-A     Methods of Administration - Civil Rights (Title VI)

7.4-A  Recission to the State's Disaster Relief Policies for the COVID-19 National Emergency

7.4-B   Temporary Extension to the Disaster Relief Policies for the COVID-19 National Emergency (June 1, 2024)