Medically Needy Pregnancy Medical with Spenddown (P99)

Created on: 
Jan 10 2018

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Who processes P99 (Medically Needy Pregnancy Medical with Spenddown) Assistance Units (AUs)

All P99 AUs are processed by Health Care Authority (HCA) users and assigned to Region 9 in one of the following MAGI CSO’s:

  • 181- Houses MAGI AUs that belong to Region 1 geographical/zip catchment
  • 182- Houses MAGI AUs that belong to Region 2 geographical/zip catchment
  • 183- Houses MAGI AUs that belong to Region 3 geographical/zip catchment

Who is eligible to receive P99 (Medically Needy Pregnancy Medical with Spenddown)?

Pregnant woman who meet the criteria in Apple Health Eligibility Manual - WAC 182-505-0115 Washington apple health - Eligibility for pregnant women are eligible for P99 medical. 

How long is the Medically Needy Pregnancy Medical with Spenddown (P99) certification period?

P99 medical is certified to the end of the final month of the base period as described in the Apple Health eligibility manual – WAC 182-505-0115 Washington Apple Health - Eligibility for pregnant women

The base period should be through the end of the final month of pregnancy, not to exceed six months. For additional information, see: 

Can a client receive P99 (Medically Needy Pregnancy with Spenddown) medical coverage while incarcerated?

When a client is active or approved under some medical coverage groups while incarcerated, they can still be eligible to receive medical assistance in a suspended status. For more information, see Suspended Medical – State Bill (SB 6430).

When is a pregnant woman not eligible for the post-partum medical extension?

If an application is not submitted and eligibility determined prior to the end of the pregnancy, the pregnant woman is not eligible for the two-month post-partum medical extension, even if medical care is authorized retroactively to cover the pregnancy.

A client can apply for medical assistance to cover the expense of the birth of the baby even after the baby is born.

When a woman is not eligible for the post-partum extension, Family Planning (P05) coverage begins the first of the month following the month the pregnancy ended.

Online Processing

How do I screen a P99 (Medically Needy Pregnancy Medical with Spenddown) Assistance Unit (AU)?

To screen P99 medical, take the following steps:

  1. Follow the instructions in How do I screen an application for a client?
  • On the Programs page, select the checkbox next to Medical.
  • On the Finalize page, click Specify Program.
  • On the Finalize - Program Details page select the following:
    • Program drop down - Select Medical Assistance (MA).
    • Medical Coverage Group drop down - Select Medically Needy Pregnancy (P99).
    • ​​Program Type drop down - Select the appropriate option from the list.

How do I process a pending P99 (Medically Needy Pregnancy Medical with Spenddown) Assistance Unit (AU)?

Processing Alternative: No Spenddown segment created when some months are approved / denied in ACES, also rejects in ProviderOne (PR 322946)

To process a pending P99 AU, follow the steps in the Process Application Months and Finalize Application chapters.

For additional information, for information on the spenddown process, see Apple Health eligibility manual – Apple Health for the Medically Needy and Spenddown overview.

How do I enter spenddown medical expenses for a P99 (Medically Needy Pregnancy Medical with Spenddown) Assistance Unit in MA - Spenddown (M) status?

To enter medical expenses to meet the client’s Spenddown liability on a P99 AU in MA Spenddown (M) status, see Spenddown - Processing - How do I enter medical expenses? 

After the expenses have been added, follow the steps in Spenddown - Processing - How do I assign medical expenses and authorize spenddown? 

What if the pregnancy ends before the original due date?

When the pregnancy ends in a month prior to the original due date entered on the Client Details page, take the following steps:

  1. In the Change of Circumstances section on the Case Actions page, use the drop down menu to select the appropriate Benefit Month and click Start Changes.
  2. On the Client Details page, change the pregnancy information to reflect the actual date the pregnancy ended.
  3. Select Review on the Navigation tree. ACES rechecks all AU/client data for errors and required verifications. If no other updates are required, select Eligibility on the Navigation tree.
  4. On the Eligibility page, click the Details link, review the data on the Eligibility Details page and click Confirm Benefits.
  5. On the Eligibility page, click Commit Changes.

What if the pregnancy ends prior to the original due date or prior to the certification end date?

If the spenddown is met prior to the birth of the baby and the baby is born early, the Medically Needy Pregnancy Medical with Spenddown (P99) Assistance Unit (AU) certification period cannot be shortened.

Check the certification period, and if the certification period ends after the two months post-partum period, screen a new P99 Assistance Unit (AU) with the correct due date using the steps in Online processing - How do I screen a Medical Needy Pregnancy Medical with Spenddown (P99) Assistance Unit (AU)? 

What if the pregnancy ends after the original due date or during the post-partum extension?

When the pregnancy ends in a month after the original due date entered on the Client Details page, take the following steps:

  1. Close the current AssistanceAU with a 500 level reason code. For additional information, see Online processing - How do I deny or terminate a case with a 500 level Reason Code?.
  2. Screen and process a new P99 AU with the correct due date.
NOTE: A P99 AU in MA Spenddown (M) status does not allow you to initiate a review. If the P99 is in Active (A) status, displays Spenddown Period Expires in a Future Month.

When do P05 (Family Planning Services) begin?

Medically Needy Pregnancy Medical with Spenddown (P99) does not trickle to a Family Planning (P05) Assistance Unit (AU). If the woman does not meet spenddown until the baby is born, she is considered eligible for family planning services. Family planning begins after the post-partum period.

Set a tickle to screen a P05 AU for the month after the post-partum period ends. For additional information, see Add a Program if the P99 is still active or see Screening an Application if the AU has closed.

Mainframe processing

How do I screen a P99 (Medically Needy Pregnancy Medical with Spenddown) Assistance Unit (AU)?

For more information on how to screen a P99 AU, see Online processing - How do I screen a P99 (Medically Needy Pregnancy with Spenddown) Assistance Unit (AU)?

How do I process a pending a P99 (Medically Needy Pregnancy Medical with Spenddown) Assistance Unit (AU)?

To process a pending P99 AU, follow the steps in the Process Application Months and Finalize Application chapters.

For additional information on the spenddown process, see Apple Health eligibility manual – Apple Health for the Medically Needy and Spenddown overview.

How do I enter spenddown medical expenses for a P99 (Medically Needy Pregnancy Medical with Spenddown) Assistance Unit in MA - Spenddown (M) status?

For information on how to enter spenddown medical expenses for a P99 AU, see Online Processing - How do I enter spenddown medical expenses for a P99 (Medically Needy Pregnancy Medical with Spenddown) Assistance Unit in MA - Spenddown (M) status?

What if the pregnancy ends before the original due date?

When the pregnancy ends in a month prior to the original due date entered on the DEM1 screen, take the following steps:

  1. From the AMEN screen, complete the following fields:
  • Selection field - Enter [R] - Interim/Hist Change.
  • Client ID field - Enter the [Client ID] for the head of household.
  • <TRANSMIT> and the ADDR screen displays.
  1. On the DEM1 screen, change the pregnancy information to reflect the actual date the pregnancy ended.
  2. <TRANSMIT> and Edit 1515 - SINCE CLIENT IS PREGNANT, YOU SHOULD DO A FIRST STEPS REFERRAL message displays at the bottom of the screen.
  3. Press <F4> to continue.
  4. Finalize and confirm the information.

What if the pregnancy ends prior to the original due date or prior to the certification end date?

If the spenddown is met prior to the birth of the baby and the baby is born early, the Medically Needy Pregnancy Medical with Spenddown (P99) Assistance Unit (AU) certification period cannot be shortened.

Check the certification period, and if the certification period ends after the two months post-partum period, screen a new P99 AU with the correct due date using the steps in Online processing - How do I screen a P99 (Medically Needy Pregnancy Medical with Spenddown) Assistance Unit (AU)? 

What if the pregnancy ends after the original due date or during the post-partum extension?

When the pregnancy ends in a month after the original due date entered on the DEM1 screen, take the following steps:

  1. Close the current AU with a 500 level reason code. For additional information, see Mainframe processing - How do I deny or terminate a case with a 500 level Reason Code?.
  2. Screen and process a new P99 AU with the correct due date. 
NOTE: A P99 in MA Spenddown (M) status – will not allow you to initiate a review. If the P99 is in Active (A) status, it gives you Edit 1003 - SPENDDOWN PERIOD EXPIRES IN A FUTURE MONTH.

When do P05 (Family Planning Services) begin?

P99 (Medically Needy Pregnancy Medical with Spenddown) does not trickle to a Family Planning Extension (P05) Assistance Unit (AU). If the woman does not meet spenddown until the baby is born, she is considered eligible for family planning services. Family planning begins after the post-partum period.

Set a tickle to screen a P05 AU for the month after the post-partum period ends. For additional information, see Add a Program if the P99 is still active or see Screening an Application if the AU has closed.

 

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.