Medicaid State Plan Documents

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:
Alisa Horn - AHorn@dhs.state.ia.us


Cover
Table of Contents
List of Attachments

Medicaid Administration
    A1 -State Plan Administration Designation and Authority
    A2 -State Plan Administration Organization and Administration
    A3 -State Plan Administration Assurances
    1.4 Tribal Consultation Requirements
    1.5 Pediatric Immunization Program

Medicaid Eligibility 
    S10 - MAGI Based Income Methodologies
    S14 - AFDC Income Standards
    S21 - Presumptive Eligibility by Hospitals
    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 - Mandatory Coverage Adult Group
    S33 - Eligibility Groups - Mandatory Coverage Former Foster Care Children
    S50 - Eligibility Groups - Options for Coverage Individuals Above 133% FPL
    S51 - Eligibility Groups - Options for Coverage Optional 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-Finanical Eligibility State Residency
    S89 - Non Financial Eligibility Citizenship and Non Citizen Eligibility
    S94 - General Eligibility Requirements Eligibility Process

 

2.0 Coverage and Eligibility

 

2.1 Application, Determination of Eligibility and Furnishing Medicaid

 

  • Attachment A: Definition of an HMO that is Not Federally Qualified

 

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

 

 

3.0 Services: General Provisions

 

3.1 Amount, Duration, and Scope of Services

 

 

3.2 Coordination of Medicaid with Medicare Part B

 

 

3.3 Medicaid for Individuals Age 65 or Over in Institutions for Mental Diseases

 

3.4 Special Requirements Applicable to Sterilization Procedures

 

3.5 Medicaid for Medicare Cost Sharing for Qualified Medicare Beneficiaries

 

3.6 Ambulatory Prenatal Care for Pregnant Women during Presumptive Eligibility Period

 

 

4.0 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

 

4.17 Liens and Recoveries

 

 

4.18 Cost Sharing and Similar Charges

 

  • Attachment A - Charges Imposed on Categorically Needy

  • Attachment C - Charges Imposed on Categorically Needy and Other Optional Groups

  • Attachment D - Premiums Imposed on Low-Income Pregnant Women and Infants

  • Attachment E - Premiums Imposed on Qualified Disabled and Working Individuals

 

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

 

  • Attachment A - Requirements for Third Party Liability- Identifying Liable Resources

  • Attachment B - Requirements for Third Party Liability- Payment of Claims

  • Attachment C - Cost-Effective Methods for Employer-Based Group Health Plans

 

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

 

4.27 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

 

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

 

4.33 Medicaid Eligibility Cards for Homeless Individuals

 

  • Attachment A - Method for Issuance of Medicaid Eligibility Cards to 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 and Certification Process

 

 

4.41 Resident Assessment for Nursing Facilities

 

4.43 Frequency and Description of Method of Compliance Oversight

 

 

 

5.0 Personnel Administration

 

5.1Standards of Personnel Administration

 

5.3Training Programs; Subprofessional and Volunteer Programs

 

 

6.0 Financial Administration

 

6.1 Fiscal Policies and Accountability

 

 

6.2 Cost Allocation

 

6.3 State Financial Participation

 

 

7.0 General Provisions

 

7.1Plan Amendments

 

7.2Nondiscrimination

 

  • Attachment A - Methods of Administration- Civil Rights Act (Title VI)

 

7.3Maintenance of AFDS Effort

 

7.4State Governor's Review

 

 

Assurance Pages

 

Drugs

 

Hospitals

 

ICF

 

ICF-MR

 

SNF

CHIP Eligibility

CS3 - Eligibility for Medicaid Expansion Program
CS7 - Separate Child Health Insurance Program Eligibility – Targeted Low-Income Children
CS12 - Separate Child Health Insurance Program Eligibility – Dental Only Supplemental Coverage
CS14 - Child Health Insurance Program Eligibility - Children Ineligible for Medicaid as a Result of the Elimination of Income Disregards
CS15 - Separate Child Health Insurance Program MAGI-Based Income Methodologies
CS17 - Separate Child Health Insurance Program Non-Financial Eligibility - Residency
CS18 - Separate Child Health Insurance Program Non-Financial Eligibility - Citizenship
CS19 - Separate Child Health Insurance Program Non-Financial Eligibility - Social Security Number
CS20 - Separate Child Health Insurance Program Non-Financial Eligibility - Substitution of Coverage
CS21 - Separate Child Health Insurance Program Non-Financial Eligibility - Non-Payment of Premiums
CS24 - Separate Child Health Insurance Program General Eligibility – Eligibility Processing
CS27 - Separate Child Health Insurance Program General Eligibility - Continuous Eligibility
CS28 - Separate Child Health Insurance Program Non-Financial Eligibility - Presumptive Eligibility for Children