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Title 8: Medicaid Page 2 Iowa Department of Health and Human Services Employees’ Manual Chapter B: Application Processing Filing a Medicaid Application Revised October 17, 2025 Which Application Form to Use and eligibility. See 8-C, Residency for more information about determining when a client is a resident of Iowa. Which Application Form to Use Legal reference: 42 CFR 435.907, 435.909, 441 IAC 76 (Rules in Process) Determine which of the following application forms to use based on the assistance the applicant is requesting: Application Form Who Should Use the Form Application for Health Coverage and Help Paying Costs, forms 470- 5170 or 470-5170(S)  Medicaid (MAGI-related and non- MAGI-related)  Hawki (Children’s Health Insurance Program or CHIP)  Iowa Health and Wellness Plan (IHAWP)  State Supplementary Assistance  Help paying for health insurance costs  Women who need treatment for breast or cervical cancer. Application for Foster Care and Subsidized Adoption Medicaid, forms 470-5535 or 470-5535(S) A child in foster care or subsidized adoption Application Referrals from and to the Federally Facilitated Marketplace (FFM) Legal reference: 42 CFR 435.1200(d) and (e), Iowa Code Section 249A.4, 441 IAC 76 (Rules in Process) and 76.3 Electronic application referrals that the Federally Facilitated Marketplace (FFM) (also known as healthcare.gov) has screened as potentially Medicaid eligible must be accepted. Medicaid eligibility shall be determined based on the referral without requiring submission of another application. When an applicant or member is determined to be ineligible for Medicaid but may be eligible for assistance at the FFM, the case shall be referred to the FFM for a determination of eligibility for financial assistance in paying for healthcare coverage.