Page 23

Title 8: Medicaid Page 21 Iowa Department of Health and Human Services Employees’ Manual Chapter A: Administration Department Responsibilities Revised January 13, 2023 Notification Notice Forms Information for more than one action can be on the same notice. When notice is generated by the ABC system, form 470-0485 or 470-0485(S), Notice of Decision, is issued. Use form 470-0486 or 470-0486(S), Notice of Decision, when manually issuing notice for Medically Needy denials or cancelations, Refugee Assistance, and other ABC programs when appropriate. Use form 470-0490, Notice of Decision: Medical Assistance or State Supplementary Assistance, when manually issuing notice for SSI-related coverage groups or State Supplementary Assistance. Use form 470-2330, Notice of Decision for Medically Needy, when manually issuing notice for Medically Needy. Attach a copy of form 470-2341, Medically Needy Spenddown Computation to the Notice of Decision for Medically Needy. When notice is generated by the ELIAS system, form 470-0485, Notice of Action, is issued. Use form 470-0485(M) or 470-0485 (MS) when manually issuing notice for cases in ELIAS.