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Effective: February 1, 2008 |
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03.20.05ar3 - MinnesotaCare for Pregnant Women (Archive) |
Archived: November 1, 2008 |
Pregnant women may become eligible for MinnesotaCare (MCRE) as new applicants, or as enrollees who become pregnant and change status. They may be eligible as a pregnant woman from the first day of the month of conception through the end of the 60-day postpartum period .
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)
Follow standard MinnesotaCare guidelines.
Eligibility as a pregnant woman may begin the first day of the month of conception. However:
l For new applicants who report a pregnancy, coverage does not begin until the first month for which they are found eligible and have paid the premium (unless they are eligible for retroactive MCRE).
l For current MCRE enrollees who report a pregnancy, see Enrollee Becomes Pregnant.
Note: When an enrollee reports a pregnancy, if the month of conception is not known, begin the pregnancy span on the first day of the current month, and adjust upon receipt of verification of the month of conception. See the MMIS User Manual for system coding information.
Renewals (standard guidelines)
Follow standard MCRE guidelines.
Pregnancy must be verified by a physician, registered nurse, licensed nurse midwife, certified nurse practitioner, or physician's assistant. Use the Request for Pregnancy Verification Form (DHS-3236) or accept any other signed document with the date of conception.
l Request verification if it is not provided. The verification must be submitted within 60 days of the request.
n If the household fails to submit verification within 30 days of the initial request for verification, send a notice informing the household that the woman will lose pregnant woman status if verification is not received within 30 days of the second notice.
n If verification is not received within 30 days of the second notice, determine whether the woman is eligible under another basis.
Note: If the verification is provided later than within 60 days of the request, pregnant woman status may be granted back to the date of conception or the effective date of coverage, whichever is later.
n If the woman is married, any pregnancy-related changes to her husband’s group status will also be affected. See Enrollee Becomes Pregnant.
Example:
Cindy and her husband Bruce enrolled in MinnesotaCare as Group One adults without children in May with income of 150% FPG. On August 15, Cindy reports that her pregnancy was confirmed at the doctor's office on August 12. Her estimated date of conception is July 7.
Action:
Change Cindy's status to pregnant woman and assign Cindy to Group Two and Bruce to Group Four effective July 1. Request verification of the pregnancy.
m If Cindy fails to submit verification within 30 days of the request, send a notice informing her that she will lose pregnant woman status and she and Bruce will be reassigned to Group One unless she submits verification within 30 days.
m If she fails to submit verification within 30 days of the second notice, change their status back to Group One adults effective the first available month.
l If pregnancy is reported but the dates are not provided, contact the client to obtain the date of conception and estimated date of delivery. If you are unable to reach her, use an estimated date of delivery pending receipt of verification.
Note: If a pregnant woman is on MA, also accept a current MAXIS STAT/PREG screen with one of the verification fields coded ”Y” as verification.
Social Security Number (standard guidelines)
Follow standard MCRE guidelines.
Pregnant women who are noncitizens:
l May be eligible with Federal Financial Participation (FFP) if they meet the immigration status requirements for federally funded MA.
l May be eligible for the same benefits but without FFP if they do not meet the immigration status requirements for federally funded MA.
See Funding Health Care for Noncitizens for further information about immigration status and federal funding.
Residency (standard guidelines)
Follow standard MCRE guidelines.
Follow standard MCRE guidelines.
Household Composition (standard guidelines)
A pregnant woman is considered a family household whether she has other children or not. Count the unborn child (or children, if a multiple pregnancy is verified) in her household size.
Note: Unlike Medical Assistance (MA), the husband of a pregnant woman is also considered part of a MinnesotaCare family household, even if he does not have any other children in the household. See Effect of Pregnancy on MCRE Eligibility Group and Determining MCRE Household Size for further information.
l Under age 21: Group One or Group Two; follow MCRE Children Under 21 guidelines.
l Age 21 or older: Group Two.
Asset Guidelines (standard guidelines)
There is no asset limit through the end of the 60-day postpartum period. Begin considering assets for women age 21 and over at the end of the postpartum period.
Note: Assets are not counted for all children under the age of 21.
l Income standard at initial enrollment is 275% FPG.
l At the end of the 60-day postpartum period, pregnant women must meet both the 275% income standard and the $50,000 income limit.
Note: Pregnant women cannot be canceled for excess income during the pregnancy and the 60-day postpartum period.
Deductions/Disregards (standard guidelines)
Follow standard MinnesotaCare guidelines.
Do not cancel pregnant women for non-payment of premiums during the pregnancy and the 60-day postpartum period. See Fail to Pay Premium/Voluntary Cancellation. Cancel other household members who fail to pay their premiums without good cause.
Make a request to forgive the portion of the past due payments attributed to the pregnant woman for covered months in the past at any of the following times:
l The other household members wish to re-enroll after their four- month penalty period.
l The household wishes to add new members or new coverage for existing household members.
l At the end of the pregnant woman's 60-day postpartum period.
Note: Do not make a request to forgive payments attributed to the pregnant woman at any time other than those listed above, or payments for future months.
Covered Services (standard guidelines)
Pregnant women are eligible for the same benefits as MA enrollees (with minor exceptions - see relationship to other groups/bases below). Also:
l Pregnant adults, like children under 21, are not subject to deductibles, co-payments, or service limitations.
l If a pregnant woman has paid any co-payments totaling $30 or more since her pregnancy diagnosis, she may request a refund from the provider to whom she paid the co-payment.
If a MCRE enrollee who becomes pregnant receives additional benefits for past months due to her pregnant status, those benefits will be covered on a fee-for-service basis rather than through her health plan.
Note: The enrollee must contact her provider directly about billing DHS for these additional benefits.
Pregnant women are not required to cooperate with establishing paternity and obtaining medical support for any child during the pregnancy and the 60-day postpartum period . See Pregnant Women and Newborns.
In the last month of a pregnant woman's 60-day postpartum period :
l MMIS will create a worker message to alert the worker that the postpartum period is ending at the end of the month.
l Make a request to forgive all unpaid premiums that have accumulated since the enrollee was designated as pregnant on MMIS that were not previously forgiven.
Relationship to Other Groups (standard guidelines)
Both MCRE and MA cover some pregnancy terminations. In some cases, the procedure may be covered by MA but not MCRE. MCRE enrollees may apply for MA to cover these costs.
l If the woman is eligible for MA with a pregnant women basis of eligibility, allow overlapping coverage for the month of the service only.
l Leave MCRE open unless the enrollee requests ongoing MA.
l To ensure that these enrollees have expanded benefits during the 60-day postpartum period, open program LL or KK for the two months following the month of pregnancy termination.
Note: Do not change the eligibility type for children under 21 on program LL or KK from C1/C2 to pregnant woman eligibility type P1/P2 as they already receive full MA benefits.
Also consider MA for Pregnant Women.