1 What Are My Rights? You have the right to: Iowa Department of Human Services Apply for any program. File an application in person, by telephone, on line, by fax or mail at any local DHS office. Have someone help you apply. Have all of your questions answered. Get information about the programs you applied for and any other DHS program that you may be able to get. Be sent a notice within 30 days of the day we get your application telling you if your application was approved. For Medically Needy, it may take up to 45 days. Have information about you and your family kept private. You Have the Right to Appeal You, or the person helping you, may request an appeal hearing if you do not agree with any action taken on your case. For Food Assistance, you can appeal in person or by telephone. For all other programs, you must appeal in writing. To appeal in writing do one of the following: Fill out an appeal electronically at https://dhssecure.dhs.state.ia.us/forms/, or Write a letter telling us why you think a decision is wrong, or Fill out an Appeal and Request for Hearing form. You can get this form at your local DHS office. Send or take your appeal to the Department of Human Services, Appeals Section, 5th Floor, 1305 E Walnut Street, Des Moines, IA If you need help filing an appeal, ask your local DHS office. You can represent yourself. Or, you can have a friend, relative, lawyer, or someone else act on your behalf. You may contact your local DHS office about legal services. You may have to pay for these legal services. If you do, your payment will be based on your income. You may also call Iowa Legal Aid at If you live in Polk County, call You Will Not Be Discriminated Against It is the policy of the Iowa Department of Human Services (DHS) to provide equal treatment in employment and provision of services to applicants, employees, and clients without regard to race, color, national origin, sex, sexual orientation, gender identity, religion, age, disability, political belief or veteran status. If you feel DHS has discriminated against or harassed you, please send a letter detailing your complaint to: Iowa Department of Human Services, Office of Human Resources, Hoover Building 1st Floor, 1305 E. Walnut, Des Moines IA ; fax (515) , or via (Food Assistance only) USDA Director, Office of Civil Rights, 1400 Independence Ave SW, Washington, DC , or call (voice) or (800) (TTY - English) or (800) (TTY - Spanish).
2 We Check What You Tell Us All Programs The information you give us may be checked by federal, state and local officials to make sure it is true. Things we might check are any listed person s: Social Security Number, job and pay, bank account amount, alien status, and amounts received from other sources like Social Security or unemployment. If any information you give us is not correct, we may deny your application. We may check records from other states to see if any person in your household can get benefits in Iowa. This may be because a person was disqualified from a program in another state. We check and use computer systems like the state Income and Eligibility Verification System, The Federal Facilitated Exchange including Internal Revenue Service (IRS), Social Security Administration (SSA), and Department of Homeland Security (DHS). If something you told us is different from what the computer system tells us, we will check to find out what is correct. We might check your information by contacting your employer, your bank or other people. To do this kind of checking with your employer, bank, or other people, we will ask you first. Things You Need to Know: You must apply for and accept any other benefits in which you may be entitled to receive. * (this is not a requirement for Food Assistance) You must give us information and provide proof, when we ask for it. You must fill out review forms when you are asked to. DHS may give your answers to law enforcement officials to catch persons fleeing to avoid the law. The Quality Control unit or Investigations unit may review your case. They may contact other people or organizations to get proof of your information. By signing this application, you give permission to release confidential information to the Quality Control unit or Investigations unit. You must cooperate with them to keep your benefits. You will have to pay back any benefits you got or that was paid to a third party on your behalf for which you were not eligible. Section 1128B of the Social Security Act provides federal penalties for fraudulent acts and false reporting in connection with these programs. Anyone who gets, tries to get, or helps any other person get assistance to which they are not entitled, is guilty of violating the laws of the state of Iowa. This includes, but is not limited to, Iowa Code Chapters 239B, 243, 249, and 249A. Your expenses may be used to figure the amount of assistance you get. You may have expenses included in your benefit calculation by reporting and giving proof of your expenses. If you do not report or give proof of your expenses, you choose not to claim the expense. You can report and give proof later, and the expense can be used for future months. Giving wrong information on purpose may result in us taking criminal or civil legal action against you. It might also mean we reduce your benefits or take money back from you.
3 Food Assistance Rules of the Food Assistance Program Follow these rules: Don t lie or hide information to get benefits that your household should not get. Don t use Food Assistance benefits to buy non-food items like alcohol or tobacco, or to pay on credit accounts. Don t trade, sell or give away EBT cards. Don t use, or have in your possession, EBT cards that are not yours and don t let someone else use your card. Don t fail to report if your household goes over its income limit. If you get Food Assistance, your worker will tell you what your household s income limit is. If your household s income goes over your limit in any month you must tell us by the 10th day of the next month. If you don t tell us on time, you might have to pay back the benefits. Penalties of the Food Assistance Program Anyone who breaks the above rules: May not get Food Assistance benefits for 1 year for the first time, 2 years for the second time, and forever for the third time; May be fined up to $250,000 or jailed up to 20 years or both; and May be kept off Food Assistance for an additional 18 months, if court ordered. If a court finds you guilty of buying, selling, or trading more than $500 in Food Assistance benefits, you will lose benefits forever. If a court finds you guilty of trading Food Assistance benefits for firearms, ammunition or explosives, you will lose benefits forever. If a court finds you guilty of trading Food Assistance benefits for controlled substances, you will lose benefits for two years the first time and forever the second time. You will not get Food Assistance for 10 years if you are found guilty of getting or trying to get Food Assistance in more than one household at a time. This penalty happens if you give wrong information about who you are or where you live. Giving wrong information on purpose may result in us taking legal action against you, either criminal or civil. It might also mean we reduce your benefits or take money back from you.
4 Things You Need to Know regarding Food Assistance: Households eligible for Food Assistance may get a notice that they are eligible for the Promoting Awareness of the Benefits of a Healthy Marriage program and a pamphlet listing those benefits. By giving this information, DHS can use different rules that may help you get Food Assistance. Your Food Assistance application will be processed using Food Assistance rules, including timeliness, notice, and fair hearing requirements even if you apply for other programs. You will not be denied Food Assistance benefits just because of denial for other programs. You may authorize someone who is familiar with your circumstances to apply for Food Assistance benefits for you. This person, called an Authorized Representative, may also use your benefits to buy food for you or report changes on your behalf. If you have a Food Assistance overpayment, DHS will give your answers to federal and state agencies as well as private claims collection agencies, to collect the overpayment. The Food Assistance office may contact other people or organizations to get proof of your information. By having signed this application, you agree that all members of your household will follow the work and training rules. Medicaid or State Supplementary Assistance (SSA) Things You Need to Know: You must tell DHS about changes within 10 days, such as: Income, including lump sum payments, such as past due child support, inheritances, settlements or cash medical support Resources or assets, which include getting an inheritance Someone moving in or out of your home Your health insurance coverage You file an insurance claim or get an attorney to recover bills paid by Medicaid Mailing or living address If you get money from another person or an insurance company to pay for your medical bills, you will need to give that money to DHS if Medicaid paid the bill. This will be used to repay bills that Medicaid paid for you. I further understand that the Department will provide documents or claim forms describing the services paid by Medicaid upon my request or the request of an attorney acting on my behalf. Such documents may also be provided to a third party when necessary to establish the extent of the Department's claim for reimbursement.
5 If the state of Iowa was made the remainder beneficiary on an annuity in order for you to qualify for Medicaid payment of long-term care, the state of Iowa will get any benefits remaining in the annuity, up to the amount of the Medicaid benefits paid. You must give the social security numbers for everyone who wants Medicaid. This is required by Section 1137(a)(1) of the Social Security Act and 42 CFR We use social security numbers to: Check income, eligibility, and Medicaid payments Determine a person s right to Medicaid Comply with federal law Match records with other agencies You can get help only for people who have a social security number or proof that they have applied for a number from the Social Security office. There are some exceptions to this. Please ask if you have questions. I understand that immigration or alien status may be subject to verification with the Department of Homeland Security (DHS) which will require submission of certain information from this application form to DHS. I further understand that information received from DHS may affect my household's eligibility and level of benefits. You must cooperate with the Health Insurance Premium Payment (HIPP) Program and enroll in a health plan through your employer if DHS asks you to. The web site explains this program. If you only want Medicaid, you can choose whether or not you want the Child Support Recovery Unit to help you get child support or health insurance from an absent parent. You can ask for the Child Support Recovery Unit s help any time. Once you ve asked for it, you must cooperate with them to continue getting Medicaid as a parent or needy caretaker. If you want your child support services stopped call to find out how to contact a local child support office. I understand that if Medical Assistance is approved, support payments intended for medical costs must be assigned and paid to the Department of Human Services to the extent of the benefits I receive. I understand that the Department may intervene, according but not limited to, Iowa Code Chapters 252A, 252B, 252C, 252D, 598, and 600B, to make claim and secure support from any person or party who may be responsible for my support or that of my children. I understand that if I receive Medicaid, the Department will pursue non-medical support for myself and my children upon my request. Medical support services include the establishment of paternity and the establishment and enforcement of medical support. If you only want Medicaid, you can apply for part of your household even if some members do not have lawful immigrant status. For example, parents who do not have lawful immigrant status may apply for their children who are U.S. citizens or qualified aliens. The Department may check your household s alien status with the DHS. Any information from the DHS may affect that individual s benefits. DHS will not be contacted about people you do not apply for. However, their income may be used to see if the rest of the household can get Medicaid.
6 If I become enrolled in a managed health care plan, I consent to disclosure of medical information, including any clinical mental health or substance abuse information, by my medical providers to the HMO, PHP, other managed care providers or to the authorized administrative body contracted by the managed care provider to determine appropriateness, quality, or utilization of services I received while enrolled in managed health care. A medical certification from the Iowa Medicaid Enterprise (IME) is needed for certain medical programs. Payments on any future unpaid medical services will be paid directly to the doctors and medical suppliers under the Medicare Insurance Program (Medicare Part B). I understand that if a change is not reported within 10 (ten) working days of when the change happens and any child for whom I am applying gets coverage when they were not eligible, I may be liable for the full amount of any payments made by the State to the health and dental plan in which the child was enrolled. These payments are approximately $200 per child each month. By signing this application, you give your permission for DHS to share: Your medical and other health care records with federal and state officials. The status of your Medically Needy case, the amount of your spend down, and the bills used to meet your spend down with the provider whose bills are being used. The premium due date for Medicaid for Employed People with Disabilities (MEPD) with your medical provider. The information on your application for Home- and Community-Based Services (HCBS) waivers with the chosen case management agency or with the Iowa Department of Public Health (IDPH) Brain Injury Services Program manager (for HCBS brain injury waiver applications). The filing date of your application with your nursing facility. By signing this application, you give your permission for your medical provider to share: Your medical history with an HMO, PHP, or other managed care provider. Information with IME Medical Services Unit to certify a medical need for certain Medical Assistance programs or services. I agree to assign medical payments from a third party to the Medicaid agency for myself and others who are eligible for Medicaid for whom I legally can assign benefits. I also agree to cooperate in obtaining medical payments from third parties. This permission ends when your Medicaid stops
7 Family Investment Program (FIP) or Refugee Cash Assistance Things You Need to Know regarding the Family Investment Program: Penalty of the FIP Program You will not get FIP for 10 years if you are found guilty of getting or trying to get FIP in more than one state at a time. This penalty happens if you give wrong information about where you live. Within 10 days of the date the change happens, you must tell DHS about changes, such as: Income, when it starts or stops, including getting an inheritance or a one-time payment of past due child support Resources or assets Someone moving in or out of your home Mailing or living address Receipt of a Social Security Number Change of school attendance of a child If your application for FIP or Refugee Cash Assistance is approved, your Food Assistance may go down or stop. To get FIP, you will need to meet with PROMISE JOBS to write and sign a plan to support your family. This plan is called a Family Investment Agreement (FIA). If FIP is approved, you will need to work with PROMISE JOBS and follow your plan to keep getting FIP. By signing this application, you agree that all members of your family who must work with PROMISE JOBS will do so. Talk with your worker if you feel you have a reason not to work with PROMISE JOBS. If a parent is absent from the home, you must give us information about that parent and help us collect child support from that parent. While you get FIP, you give up your rights to child support for the months you are on FIP. The state of Iowa will keep your child support to pay back the money you get from FIP. You must cooperate with the Child Support Recovery Unit.
8 INFORMATION FOR THOSE APPLYING FOR WIC OR MATERNAL AND CHILD HEALTH SERVICES I understand that a declaration of income and persons in my family and living in my household is necessary to ensure that federal and state funds are directed to those persons least able to secure services from other sources. I understand that the Maternal and Child Health Director of the Iowa Department of Public Health, the WIC Director, or their designees shall have access to all information available from records maintained by the agency providing maternal health, child health, or WIC services. Information for those Applying for Presumptive Medicaid Services I understand that my answers to some questions will not impact the presumptive Medicaid eligibility decision. These answers are needed for the Department to make a decision for ongoing Medicaid only. I understand that, if I am only applying for presumptive Medicaid, not all of my information will be checked against data in computer systems like the State Income and Eligibility Verification System. I understand that applicants for presumptive Medicaid for pregnant women and for the breast and cervical cancer treatment (BCCT) program choose whether to have their application referred to the Department for an ongoing Medicaid determination. If I choose to have my application forwarded to the Department, the Department will verify income, citizenship, alien status, identity, and other information as necessary during the formal Medicaid eligibility determination. I understand that all other presumptive Medicaid applications are automatically referred to the Department of Human Services for an ongoing Medicaid eligibility determination. During the formal Medicaid eligibility determination, the Department will verify income, citizenship, alien status, identity, and any other information as necessary. I understand all Presumptive Medicaid is granted on a daily basis and may be terminated on any given day, without notice, once it is determined that the individual is no longer presumptively eligible. I understand there are no appeal rights under the presumptive Medicaid programs.
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