GENERAL LETTER NO. 6-AP-169 - Employees’ Manual Update - Income Maintenance Programs Appendix

Sep 19, 2026

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General Letter No. 6-AP-169 announces revisions to Iowa Medicaid’s Employees’ Manual, Title 6 Appendix, specifically the Income Maintenance Programs Appendix covering Contents 1-13, 2 and 3. The update renames and refreshes 470-0398 with new branding and vendor/agency name content, adds new form 470-0399 as a supplement, and revises 470-5771 and 470-5771(S) to reflect extended eligibility dates. Effective immediately and directs removal and destruction of specified superseded pages.

LanguageEnglish

CategoryLetters

FormatPDF

Pages16

Reading Time6 min

AccessFree to download

Summary

Effective Date

Material Superseded

Additional Information

Form index (Absent Parent Information through Child Support Information Request)

October 11, 2024 GENERAL LETTER NO. 6-AP-169 ISSUED BY: Bureau of Financial, Food, and Work Supports Division of Community Access and Eligibility Iowa Medicaid SUBJECT: Employees’ Manual, Title 6 Appendix, Income Maintenance Programs Appendix, Contents 1-13, 2 and 3, revised; forms revised and new. Summary This chapter is revised to ▪ Update and rename 470-0398, Accident or Injury Request for Information: First Request to reflect new branding and content regarding vendors and agency names ▪ Create 470-0399, Accident or Injury Request for Information: Final Notice as a new document to supplement 470-0398 ▪ Update forms 470-5771 and 470-5771(S), Report of Stolen SNAP Benefits, to reflect extended eligibility dates Effective Date Immediately. Material Superseded Remove the following pages from Employees’ Manual, Title 6 Appendix, and destroy them: Page Contents 1-13 2 and 3 470-0398 470-5771 470-5771(S) Date September 27, 2024 September 27, 2024 06/24 04/24 04/24 Additional Information Refer questions about this general letter to your area income maintenance administrator. Absent Parent Information, Form 470-3773 or 470-3773(S) ....................................... 1 Accident or Injury Request for Information: First Request, Form 470-0398 ............ 2 Accident or Injury Request for Information: Final Notice, Form 470-0399 ............... 3 Account Transfer Error, Form 470-5437 ...................................................................... 4 Addendum to Application and Review Forms for Release of Information, Form 470-4670 or 470-4670(S) .......................................................................................... 5 Addendum to Application for Help with Medicare Prescription Drug Plan Costs, Form 470-4167 .......................................................................................................... 7 Adding an EBT Cardholder, Form 470-3983 or 470-3983(S) ...................................... 8 Adjustment to Overpayment Balance, Form 470-0010............................................. 10 Affidavit of Citizenship, Form 470-4373 or 470-4373(S) ........................................... 12 Affidavit of Identity, Form 470-4386 or 470-4386(S) ................................................. 13 Agreement for Automatic Deposit, Form 470-0261 or 470-0261(S) ......................... 14 Agreement for Telephone Hearing, Form 427-0415 or 427-0415(S) ........................ 15 Agreement to Pay a Debt, Form 470-0495 or 470-0495(S) ....................................... 16 Agreement to Sell Excess Property, Form 470-2909................................................ 17 Annuity Release of Information, Form 470-4699 ...................................................... 19 Appeal and Request for Hearing, Form 470-0487 or 470-0487(S) ........................... 20 Appendix A for Health Coverage, Form 470-5433 or 470-5433(S) ........................... 23 Application for COVID-19 Testing Coverage, Form 470-5618 or 470-5618(S) ........ 24 Application for Extra Help with Medicare Prescription Drug Plan Costs, Form SSA-1020B-OCR-SM .............................................................................................. 25 Application for Foster Care and Subsidized Adoption Medicaid, Form 470-5535 or 470-5535(S) ............................................................................................................. 26 Application for Health Coverage and Help Paying Costs, Form 470-5170 or 470-5170(S) ............................................................................................................. 27 Asset Verification System (AVS) Payment Worksheet, Form 470-5498 ................. 29 Attribution of Resources Appeal Summary, Form 470-3144 ................................... 31 Authorization for Examination and Claim for Payment, Form 470-0502 ................ 33 Authorization for Release

FAQs

What document section does General Letter No. 6-AP-169 revise?

It revises the Employees’ Manual, Title 6 Appendix, Income Maintenance Programs Appendix, covering Contents 1-13, 2 and 3.

Which forms are updated or newly created in this revision?

470-0398 is updated and renamed, 470-0399 is created as a new document supplement, and 470-5771 and 470-5771(S) are updated to reflect extended eligibility dates.

What actions are required for the superseded material?

Remove the specified pages from the Employees’ Manual, Title 6 Appendix, and destroy them, effective immediately.

Sep 19, 2026

Upload by Connor