Pregnancy and Women's Health - Medical Programs
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Pregnancy and Women's Health - Medical Programs


Revised November 14, 2013



WAC 182-505-0115Washington apple health -- Eligibility for pregnant women.
WAC 182-505-0120Breast and cervical cancer treatment program (BCCTP) for women--Client eligibility.

IMPORTANT NOTE

   

On October 1, 2013, the new MAGI methodology replaced the legacy Medicaid net income methodology for determining eligibility for the MAGI-based Family, Pregnant Women, and Child medical programs. MAGI methodology follows Internal Revenue Service (IRS) rules for counting income -- in other words, if it is included in adjusted gross income (AGI), it is countable income -- with certain exceptions.

In addition, on October 1, 2013, the new Adult medical program started to accept applications for coverage to begin on January 1, 2014, using the MAGI methodology.

Please see the ACA Transition Plan for more information.

If you have clients who wish to apply for the MAGI-based Family, Pregnant Women, Child, or Adult medical programs, they can apply in the following ways:

Washington Healthplanfinder
PO Box 946
Olympia, WA 98507

Clients who have questions regarding their eligibility for MAGI-based medical assistance should call the Medical Eligibility Determination Service at the Health Care Authority at 1-855-923-9357. Clients who have questions about applying online for MAGI-based medical assistance should call the Health Benefit Exchange at 1-855-923-4633.

While the WACs on this page have been updated (or noted as repealed where applicable) effective October 1, 2013, the Clarifying Information below applied to Pregnant Women Medical programs prior to October 1, 2013 and is now out of date.

 


 


WAC 182-505-0115
WAC 182-505-0115

Effective October 1, 2013

WAC 182-505-0115 Washington apple health -- Eligibility for pregnant women.



(1) A pregnant woman is eligible for the Washington apple health (WAH) for pregnant women program if she:

(a) Meets citizenship or immigration status under WAC 182-503-0535;

(b) Meets Social Security number requirements under WAC 182-503-0115;

(c) Meets Washington state residency requirements under WAC 182-503-0520 and 182-503-0525; and

(d) Has countable income at or below the limit described in:

(i) WAC 182-505-0100 to be eligible for categorically needy (CN) coverage; or

(ii) WAC 182-505-0100 to be eligible for medically needy (MN) coverage. MN coverage begins when the pregnant woman meets any required spenddown liability as described in WAC 182-519-0110.

(2) A noncitizen pregnant woman who does not need to meet the requirements in subsection (1)(a) or (b) of this section to be eligible for WAH and receives either CN or MN coverage based upon her countable income as described in subsection (1)(d) of this section.

(3) The assignment of medical support rights as described in WAC 182-503-0540 does not apply to pregnant women.

(4) A woman who was eligible for and received coverage under any WAH program on the last day of pregnancy is eligible for extended medical coverage for postpartum care for a minimum of sixty days from the end of her pregnancy. This includes women who meet an MN spenddown liability with expenses incurred no later than the date the pregnancy ends. This extension continues through the end of the month in which the sixtieth day falls.

(5) All women approved for WAH pregnancy coverage at any time are eligible for family planning services for twelve months after the pregnancy ends.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

CLARIFYING INFORMATION

  1. First Steps:

    1. The Maternity Care Access Act was implemented in 1989. It provides for a package of services for pregnant women who are eligible for DSHS medical programs such as Maternity Support Services. These services are referred to as First Steps Services. Sometimes the pregnant woman's medical programs are also referred to as First Steps.   

    2. All pregnant women, whether receiving cash assistance or only medical coverage, are referred to the First Steps Social Service Specialist.

    3. Non-Cooperation with DCS:

  2. A pregnant woman is not required to cooperate with the Division of Child Support during the pregnancy through the end of the post partum period. Therefore even if she is not cooperating, the non-cooperation does not affect her medical benefits.

  3. Program Priorities:

    The following priority is used to establish eligibility for pregnant women:

    Categorically needy (CN) (P02)
    Medically needy (MN) (P99)
    Non-citizen pregnancy program for women who do not meet alien status for other medical programs (P04)


NOTE: Pregnancy medical has continuous eligibility. Changes in income do not affect these medical programs during the certification period.

WORKER RESPONSIBILITIES

  1. Pregnant children:

    1. Determine eligibility for pregnant children under the age of 19 for children's CN medical program (F06), unless the pregnant child is living with her parents and is requesting medical benefits for the pregnancy only. In this case use the P02 program. Children's CN medical has a higher income level and the child continues to be eligible beyond the postpartum extension.

    2. If the child's income exceeds the CNIL, then determine eligibility for the MN program (P99). See: SPENDDOWN.

    3. Consider if there is reasonable cause to report child abuse or neglect. See the CHILD ABUSE AND NEGLECT REPORTING section of the EA-Z manual.

  2. Alien: 

    1. Determine eligibility for the non-citizen pregnancy program (P04) for aliens who are not eligible for other medical programs. This program has full scope coverage.

    2. If a pregnant alien's income exceeds the CNIL, determine eligibility for the MN program (P99). See SPENDDOWN.

  3. Financial responsibility and pregnant women: 

    1. When a pregnant woman is not married to the father of her unborn child, do not consider the income of the father of her unborn child unless he actually contributes an amount.

    2. Count only the income of a pregnant minor's parent(s) that is actually contributed to the pregnant child.

  4. Verification of Pregnancy:

    See the VERIFICATION section of the EA-Z manual.

  5. Household size: 

    Consider the unborn child(ren) when determining the household size. Add one person for each unborn.  This applies to all medical programs.

  6. Non cooperation with the Division of Child Support:

    A pregnant woman is not required to cooperate with the Division of Child Support for medical programs during the pregnancy and post partum period. If a pregnant woman receives TANF and is coded in ACES for non cooperation with DCS, open pregnancy medical (P02/P04) so that her medical benefits do not end.

  7. Estimated Due Date: 

    1. The client must provide the month, day, and year of the Estimated Due Date (EDD) of delivery.   

    2. If a client indicates they are going to terminate the pregnancy, use the date of the procedure, if known.

    3. If a client is unsure that she will terminate the pregnancy, then use the date of birth for the full-term pregnancy as the EDD.  Instruct the client to notify the office if/when she terminates the pregnancy.

    4. If a home pregnancy test is used to verify the pregnancy, use the client's estimated date of delivery.

  8. Applications made after the pregnancy ends: 

    1. The client is not eligible for the two-month postpartum medical extension, when medical care is authorized retroactively to cover the pregnancy; and

    2. The client is eligible for the twelve-month medical extension for family planning services, even if she is determined eligible retroactively to cover the pregnancy after the pregnancy ends.

  9. End of the pregnancy: 

    1. If the pregnancy ends before the expected due date through birth, miscarriage, or abortion, correct the estimated date of delivery on the DEM1 Screen in ACES to ensure a timely program change to family planning services (P05).

    2. Adjust the review date to ensure the client gets additional CN coverage if the pregnancy ends in a month later than the expected due date.

    3. When a woman is terminated from a cash grant and is not eligible for any other medical program, review for eligibility for family planning services if her pregnancy ended in the previous twelve-month period.

  10. Case Pending Spenddown:

    1. When a pregnant woman applies for medical before the baby is born but does not meet spenddown until the baby is born, the woman is considered eligible for medical benefits at the time of the baby’s birth. Therefore, the woman is eligible for:
      1. The extended post partum care: and

      2. Family planning services.

    2. The base period should be through the end of the month in which the baby is due but not to exceed 6 months.

  11. Post Partum Period and Family planning extension:

    1. ACES continues the Pregnancy Medical benefits until the end of the month of the 60th day after the pregnancy ends (post partum period) as long as the mother received Medicaid at the time of the baby's birth. ACES automatically trickles to the Family Planning Medical for the ten month period after the pregnancy medical benefits end.
  12. Newborn Medical Coverage:

It is important to add a newborn to medical as soon as possible after birth, so the baby has its own client identification number.  This can avoid coverage problems for the baby.  

  • If the mother is served fee-for-service on the date of the baby's birth, a newborn is covered by Medicaid fee-for-service under the mother's client ID through the month that includes the baby's 60th day of life.
  • Managed care organizations (MCOs, Healthy Options) only cover a newborn on the mother's client ID for the month(s) in which the first 21 days of life occur.  After that, a newborn must have its own client identification number, or the only medical coverage the newborn receives is fee-for-service, up through the month that includes its 60th day of life, or until the newborn is assigned its own client ID number, whichever is earlier.
  • Once the newborn has been issued its own client ID number, the newborn cannot use the mother's client ID number.

 

 

Verification of Pregnancy:

See the VERIFICATION section of the EA-Z manual.


NOTE:

Due to continuous tracking in ACES there is no longer the need to open a newborn on F05 medical unless you do not have the required verification (SSN).  If you open the newborn on F06 or F05 you must use the newborns date of birth as the application date.  If the existing case is terminated at review for the previous members the newborn will continue on coverage for 12 months from the date added to the program.  If all children and newborn are eligible as one AU at next review (including SSN for newborn) combine children to one AU.   This will minimize the number of reviews to the household and issue a new 12 month certification for all children.


WAC 182-505-0120

WAC 182-505-0120

Effective January 1, 2014

WAC 182-505-0120 Breast and cervical cancer treatment program (BCCTP) for women--Client eligibility.

1. Effective July 1, 2001, through December 31, 2013, a woman is eligible for categorically needy (CN) coverage under the federally funded breast and cervical cancer treatment program (BCCTP) only when she:

a. Has been screened for breast or cervical cancer under the center for disease control (CDC) breast and cervical cancer early detection program (BCCEDP);

b. Is found to require treatment for either breast or cervical cancer or for a related precancerous condition;

c. Is under sixty-five years of age;

d. Is not eligible for another CN medicaid program;

e. Is uninsured or does not otherwise have creditable coverage;

f. Meets residency requirements as described in WAC 182-503-0520;

g. Meets Social Security number requirements as described in WAC 182-503-0515;

h. Meets the requirements for citizenship or U.S. national status or "qualified alien" status as described in WAC 182-503-0535; and

i. Meets the income and asset limits that are set by the CDC-BCCTP.

2. A woman who is eligible for BCCTP on or before December 31, 2013, will continue to receive coverage after December 31, 2013, for the certification period if:

a. She applies for Washington apple health (WAH) coverage on or before December 31, 2013; and

b. She is determined to be not eligible for any other WAH pro-gram whose scope of services (as described in WAC 182-501-0060) includes breast and cervical cancer treatment.

3. The WAH coverage referred to in subsection (2) of this section will continue uninterrupted for the certification period and will be under one of the following programs:

a. A WAH program that the woman is determined eligible for, other than the state-only funded breast and cervical cancer treatment continuation program (BCCTCP); or

b. BCCTCP if the woman is determined not eligible for any other WAH program.

4.The certification period breast and cervical cancer treatment covered under subsection (2) of this section is the full course of treatment as certified by the CDC-BCCEDP.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

CLARIFYING INFORMATION

  1. The Department of Health (DOH) administers the CDC-BCCEDP program for the State of Washington through their Breast and Cervical Health Program. This program provides breast and cervical cancer screening services for low-income women. CDC also directly contracts with certain tribal entities for this screening service. Until recent passage of federal and state legislation, many of these women did not have access to medical coverage for treatment of the breast and cervical cancer identified through the above screening services.

  2. A woman can access the BCCTP only through a CDC-BCCEDP facility. When a woman meets the eligibility criteria, staff at a CDC-BCCEDP facility will send Medical Eligibility Determination Services (MEDS) the application developed specifically for this program.

  3. A woman who is not eligible for the BCCTP solely because she does not meet the citizenship or alien status requirements described in WAC 182-505-0120(2), is eligible for medical coverage under the Alien Emergency Medical Program. The woman is related to a Medicaid program through the BCCTP and the need for cancer treatment meets the emergency medical condition criteria. For more information on the AEM program, refer to the Emergency Assistance chapter.


NOTE: Although men may be diagnosed with breast cancer, the federal requirements of this Medicaid program limit medical coverage to only women as described in this section.

WORKER RESPONSIBILITIES

  1. If a woman contacts CSO staff about this program, refer the woman to her local Breast and Cervical Health provider, as described in Clarifying Information - (1.) when she wants screening services for breast and cervical cancer and has not yet been diagnosed.  The Department of Health web site provides a list of screening clinics.  When you get to their website, click on "How to Enroll" and then the county you are interested in.

  2. If an application/review is received indicating breast cancer; screen S02, determine eligibility for the SSI-related program and refer her to the local BCCTP provider found on Department of Health web site above.

  3. Notify MEDS(1-800-562-3022 x 16136) when a woman active on BCCTP (S30) applies and is determined eligible for another CN medical program to terminate BCCTP (S30) coverage.

  4. If a woman applies in the local CSO and is found eligible for ABD cash assistance, she continues to be eligible for CN coverage but not under the BCCTP program. Notify MEDS to terminate coverage under the BCCTP program. Until ACES support for this program is completed, open ABD. At incapacity review, determine whether the client is still receiving the prescribed course of treatment for breast or cervical cancer.


ACES Procedures

Medical - Pregnancy Medical (P02) / P04)

Sneede/Kizer Coding for:

Modification Date: November 14, 2013