*** The Health Care Programs Manual (HCPM) has been replaced by the Minnesota Health Care Programs Eligibility Policy Manual (EPM) as of June 1, 2016. Please refer to the EPM for current health care program policy information. ***
Effective: June 1, 2012 |
|
03.45.30 - Medical Assistance for Breast/Cervical Cancer (MA-BC) |
Archived: June 1, 2016 (Previous Versions) |
Women who need treatment for breast or cervical cancer, including precancerous conditions and early stage cancer, may be eligible for Medical Assistance (MA) under the Breast/Cervical Cancer basis of eligibility (MA-BC) if they meet all of the following conditions:
l Have been screened by the Sage Screening Program and used program funds to pay for the screening.
l Need treatment, including diagnostic services to determine the extent and course of treatment for breast or cervical cancer, including precancerous conditions and early stage cancer.
l Are under age 65.
l Are not eligible for MA without a spenddown under any of the following bases:
n Children under age 19 who have a children under 21 basis of eligibility.
Note: Children ages 19-20 who are eligible under this basis may be eligible for MA-BC.
n Blind or disabled receiving SSI who have income at or below 100% FPG and are eligible for the Disabled Adult Children disregard, Widow/Widowers' disregard, or Pickle disregard.
n Blind or disabled and receiving Minnesota Supplemental Aid (MSA).
Note: A woman who is eligible under one of these bases without a spenddown, may not be enrolled in MA-BC. A woman who is eligible under a basis different from those listed above may choose between that basis and MA-BC.
l Are not covered by a creditable health insurance plan.
l Have an immigration status that qualifies them for federally or state-funded MA.
Eligibility factors and links to standard program guidelines are provided below.
Citizenship/Immigration Status.
Insurance and Benefit Recovery.
Relationship to Other Groups/Bases.
Application Process (standard guidelines)
Women who are screened through the Sage Screening Program and found to need treatment should apply for MA-BC. Women may apply for MA-BC coverage by:
l Submitting an MA-BC application with ApplyMN. ApplyMN automatically routes the application to the county agency.
l Submitting the Minnesota Medical Assistance Breast and Cervical Cancer Coverage Group Application/Renewal (DHS-3525) to their county agency.
l Receiving a presumptive eligibility determination through a participating medical provider.
Note: The woman’s doctor will complete a Minnesota Department of Health Sage Enrollment form, Sage Return Visit form, or Colposcopy Program form. Do not require any other documentation to establish that the applicant needs treatment or diagnostic services to determine the extent and course of treatment for breast or cervical cancer, including precancerous conditions and early stage cancer.
If a provider determines presumptive eligibility, the date of application is the date the provider grants presumptive eligibility.
If the provider does not determine presumptive eligibility, the date of application is the date the county agency receives the MA-BC Application/Renewal (DHS-3525).
See Application Process for MA-BC and Presumptive Eligibility Providers.
The earliest date of eligibility for MA-BC is three months before the date of application or the first day of the month in which the woman was screened under the Sage Screening Program, whichever is later.
Note: Women who are granted presumptive eligibility for MA-BC must be found eligible for ongoing MA-BC before retroactive eligibility is granted.
Renewals (standard guidelines)
Review MA-BC eligibility annually.
Mail an MA-BC Application/Renewal (DHS-3525) and Certification of Further Treatment Required (DHS-3525A) to the enrollee following the timelines in MA Renewals. The enrollee does not need to provide any other proof of the need for further treatment.
Use DAIL/TIKL in MAXIS to set a reminder of when to mail the renewal. Set the TIKL for the 10th month after the month of application.
Request verification of immigration status for women who report they are noncitizens and request ongoing MA-BC coverage.
Social Security Number (standard guidelines)
l Presumptive eligibility: An SSN is not required.
l Ongoing MA-BC: Follow standard MA guidelines.
MA-BC clients are not required to document their citizenship and identity or immigration status as a condition of eligibility during the presumptive eligibility period. Obtain documentation for enrollees who file an application for ongoing coverage. See Citizenship Verification Requirements for additional information.
l Presumptive eligibility: MA-BC coverage for the presumptive eligibility period is always federally funded.
l Ongoing MA-BC: Women must be U.S. citizens or have an immigration status that qualifies them for either federally funded MA (program MA) or state-funded MA (program NM). MA-BC is federally funded for women who have an MA-qualifying status and state-funded for those who have a program NM status.
Note: Because MA-BC does not have an income standard, there is no need to require sponsor information or apply sponsor deeming provisions for MA-BC.
Residency (standard guidelines)
Follow standard MA guidelines.
Some women may have insurance barriers that prevent them from using the MA-BC basis of eligibility. Contact an applicant who reports other health care coverage to determine if it is creditable coverage.
1. An applicant is not eligible for MA-BC if the coverage is any of the following creditable health insurance plans:
n Group health care coverage, unless the plan does not cover the needed cancer treatment.
n Individual health care coverage, unless the plan does not cover the needed cancer treatment.
n Medicare.
n MA.
n Armed forces insurance (TRICARE, CHAMPVA).
n Minnesota Comprehensive Health Association (MCHA).
Exception: A woman may be eligible for MA-BC if the creditable coverage she has will not cover her cancer treatment. This includes, but is not limited to women whose treatment will not be covered due to any of the following:
r There is a pre-existing condition exclusion.
r There is an HMO affiliation period.
r There is a lifetime cap under the plan which has been met.
Note: Co-payments and deductibles are not considerations for this exception.
Note: Do not require verification that a policy will not cover the cancer treatment. Accept the applicant’s statement of a policy’s limitations.
2. If the coverage does not meet the definition of creditable coverage or is creditable coverage but will not cover the cancer treatment, enter insurance information in MMIS and determine if the premium is cost effective.
Example:
Mary applies for MA-BC. She has a group health insurance policy that has a $3 million individual lifetime cap. She has just begun treatment, so the cap has not been met.
Action:
The insurance policy will still cover Mary’s cancer treatment because the cap has not been met. Thus, it does not meet an exception to creditable coverage. Mary is not eligible for MA-BC because she has creditable coverage.
Household Composition (standard guidelines)
Not applicable - there is no income or asset test.
Not applicable - there is no income or asset test.
Asset Guidelines (standard guidelines)
There is no asset limit.
There is no income limit.
Deductions/Disregards (standard guidelines)
There is no income limit.
Individuals are eligible without a spenddown because there is no income limit.
MA-BC enrollees are eligible for all MA-covered services for as long as their doctor determines they need treatment.
Women eligible under this basis are excluded from managed care enrollment.
A woman who was diagnosed with breast or cervical cancer by a participating Sage Screening Program provider, but not using Sage funds, may be screened retroactively for possible MA-BC eligibility with Sage funds.
Note: Each Sage clinic decides if they will perform retroactive screenings to be covered under Sage program funds.
Redetermine MA under another basis for MA-BC enrollees who no longer need treatment for breast or cervical cancer, including precancerous conditions and early stage cancer.
Presumptive eligibility ends the last day of the month following the month that it begins.
Authorized providers will approve presumptive MA-BC eligibility for a minimum of 30 days from the application date.
A woman who is eligible for MA without a spenddown under another basis (other than the bases listed at the beginning of this section), may choose between that basis and MA-BC. If she chooses the other basis and she becomes ineligible for the other basis at a later date, redetermine eligibility for MA-BC.
Note: Require verification of the continuing need for treatment if the Sage Screening Program form is more than 12 months old.
A woman who is eligible for MA with a spenddown may choose MA-BC, provided all other eligibility factors are met.
Example:
Joyce is eligible for MA with a parent basis. Her spenddown is $200 a month. She is screened by the Sage Screening program and needs treatment for breast cancer. She meets all eligibility criteria for MA-BC.
Action:
Allow Joyce to choose between MA with a spenddown and MA-BC.