Safety Net Funding (SNMIS)

Behavioral Health Services funding is intended to support at-risk populations, including but not limited to children, youth, young adults, individuals with disabilities, pregnant and parenting women, older adults, and people with limited access to financial resources. lowa residents who meet the requirements below are eligible to receive behavioral health services from the enrolled provider(s) of their choice. Reimbursement for behavioral health services is subject to the financial eligibility and resource requirements for lowa residents in Iowa Administrative Code (IAC) 441-301.1. A copy of the completed form, including the determination of eligibility, must be provided to the individual receiving services or their guardian.

Part I. Income at or below 200% of the Federal poverty guidelines as published by the U.S. Department of Health and Human Services. https://www.hhs.gov/

To determine financial eligibility, individuals must provide one of the following forms of income verification, as listed below. Please indicate which form of financial documentation is being provided:*

Pay stub, wages verification, or SSI benefits statementIowa Workforce Development "white sheet"No IncomeFederal Income tax filingOther form of documentation

File Upload*

A copy of the documentation used to demonstrate income must be provided prior to initiating behavioral health services, with a copy of the documentation maintained in the individual's services file.

Part 2. Resource limits are equal to or less than $2,000 in countable value for a single-person household or $3,000 in countable value for a multi person household.

	Value
Houses (do not include the primary residence; include second homes or investment property)
Automobiles (one vehicle is exempt; only include additional autos)
Cash on hand
Checking accounts
Savings accounts
Certificates of Deposit
Trust funds
Stocks and Bonds
Life Insurance cash surrender value (only include if value greater than $1500 per insured)
Burial Plots or Trusts (exclude any limited in value as allowed under Medicaid)

Identifying Information: You may have someone help you complete this section.

Client Name*

First NameLast Name

Client Address (place of residence)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Client County of Residence Must be a Resident in the State of lowa*

Household Size:*

By signing this document, I attest that the financial information provided is accurate and demonstrates my eligibility.

Client Signature*

Date*

Date

Witness Signature*

Date

470-0166 (06/25)

You Have the Right to Appeal

What is an appeal? An appeal is asking for a reconsideration because you do not like a decision that was made relating to an eligibility determination or denial of behavioral health or disability services. You have the right to file an appeal if you disagree with a decision. You do not have to pay to file an appeal. [441 Iowa Administrative Code Chapter 223 for Disability Services or Chapter 303 for Behavioral Health].

How do I appeal? Appeals must be done in writing. The appeals form for the behavioral health and disability services system can be found at https://hhs.iowa.gov/appeals. There are multiple ways to file an appeal. Choose the one that works for you:

• Email: appeals@hhs.iowa.gov

• FAX: (515) 564-4044

• Mail: Iowa Department of Health and Human Services, Appeals Bureau,

321 E 12th Street, Des Moines, Iowa 50319

We will let you know in writing that we received your appeal.

How long do I have to appeal? You have 120 calendar days to file an appeal from the date of the eligibility determination or denial of services.

How will I know if my appeal was accepted? If the appeal request is granted, you will be given a

chance to submit a written statement and documentation to support your case. You will have 14 calendar days from the date of the acknowledgment letter to provide this information. Then, you should receive a written Proposed Decision from HHS within 30 calendar days that explains the decision and next steps that may be available to you. You will get a letter telling you if your appeal is denied.

Can I have someone else help me? You or someone else, such as a friend or relative, can tell why you disagree with the HHS’s decision. You may also have a lawyer help you, but HHS will not pay for one. Your county HHS office can give you information about legal services. The cost of legal services will be based on your income. You may also call Iowa Legal Aid at 1-800-532-1275.

470-0166 (06/25)

Policy Regarding Discrimination, Harassment, Affirmative Action and Equal Employment Opportunity

It is the policy of the Iowa HHS 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, religion, age, disability, political belief or veteran status.

If you feel HHS has discriminated against or harassed you, please send a letter detailing your complaint to: Iowa HHS, Lucas Building, Bureau of Human Resources, 4th Floor, 321 East 12th Street, Des Moines, IA 50319 -0114 or via email HR@hhs.iowa.gov.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.), should contact the agency (state or local) where they applied for benefits. Additionally, program information may be made available in languages other than English.

This institution is an equal opportunity provider.

470-0166 (06/25)

Behavioral Health Services Eligibility Form