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Effective: October 1, 2008 |
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03.25.05ar3 - Medical Assistance (MA) for Pregnant Women (Archive) |
Archived: November 1, 2009 |
All pregnant women have a basis of eligibility for MA. Pregnant women who are not eligible for federally funded MA because of their immigration status may be eligible for MA funded by the State Children's Health Insurance Program (SCHIP) (program NMED, eligibility type PC) or state-funded MA (program NMED , eligibility type PX). This basis is potentially available 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)
A woman may apply under this basis during or after her pregnancy.
Pregnant women who are applying only for MA may apply at certain outstation locations other than the county agency. These locations include federally qualified health centers (FQHC), disproportionate share hospitals (DSH), and the Indian Health Service (IHS).
Process MA applications within 15 calendar days for pregnant women.
Note: If they request an in-person interview, schedule the interview within five days of the date of application and determine eligibility within ten days of the date of the interview.
Eligibility may begin on the first day of the month of conception, but no sooner than three months before the month of application.
Note: Even if a woman is not eligible for the birth month, she may be eligible under this basis for the postpartum period only.
Example:
Rachel applies for MA in October, and requests retroactive coverage for September. She gave birth to Billy on September 17.
For the six-month budget period that includes September, she has a spenddown that she is unable to meet. However, her anticipated income is under the pregnant woman income standard for the postpartum months (October and November).
Action:
Deny eligibility for September, and approve Rachel for October and November under the pregnant woman basis. If she is unable to meet a spenddown for the remaining four months of the budget period under a non-pregnant woman basis, close her for December.
Note: Because Rachel was not MA-eligible for the birth month, Billy does not have an auto newborn basis of eligibility.
Renewals (standard guidelines)
Pregnant women are exempt from renewal requirements through the end of the 60-day postpartum period .
Note: See end of eligibility in this group/basis below for information about what is required at the end of the postpartum period.
The pregnancy must be verified by a physician, registered nurse, licensed nurse midwife, certified nurse practitioner, or physician’s assistant. If the pregnancy has already been verified for MinnesotaCare or a cash assistance program, do not require additional verification.
MA may be approved for pregnant women who meet all other eligibility requirements before the verification of pregnancy is received. If an applicant or enrollee reports she is pregnant but does not provide verification:
1. Use the estimated dates of conception and delivery reported on the application. If that information was not reported, contact the woman to obtain these dates.
Note: If you are unable to reach her, use an estimated date of delivery pending receipt of verification.
2. If she meets all other eligibility requirements, approve MA under this basis and request verification.
3. Verification of pregnancy must be submitted within 60 days of the request for verification. If verification is not received, determine whether the woman is eligible under another basis.
Social Security Number (standard guidelines)
Pregnant women who are noncitizens with an undocumented or nonimmigrant status and eligible for SCHIP-funded MA (program NMED, eligibility type PC) or Emergency Medical Assistance (EMA) for labor and delivery only are not required to provide SSNs.
Pregnant women who are U.S. citizens and noncitizens who have an immigration status that qualifies for federal financial participation (FFP) may be eligible for federally funded MA through the 60-day postpartum period .
Pregnant noncitizens with a status that does not qualify for FFP may be eligible for SCHIP -funded MA (program NMED, eligibility type PC) through the birth month and state-funded MA (program NMED, eligibility type PX) for the 60-day postpartum period.
SCHIP -funded MA (program NMED, eligibility type PC) may be available through the birth month for pregnant noncitizens with a status that does not qualify for FFP who are otherwise eligible for NMED if they meet all of the following criteria:
l Do not have other health insurance. This includes:
n an employer health plan
n medical service policy
n hospital policy
n HMO coverage
n TRICARE
n Veteran's Affairs policy
l Are eligible without a spenddown .
Access to or the availability of other health insurance, such as through an employer plan, is not a barrier to SCHIP-funded MA. An applicant or enrollee is ineligible for SCHIP-funded MA only if she actually has other health coverage.
Pregnant noncitizens with a status that does not qualify for FFP who:
l Meet the above criteria should be coded in MMIS with eligibility type ”PC” through the birth month, and with eligibility type "PX" for the postpartum period.
l Do not meet the above criteria (they have other health insurance or must meet a spenddown to be eligible for MA) are eligible for state-funded MA (NMED), and should be coded with eligibility type "PX," for both the pregnancy and the postpartum period.
Note: It is not necessary to change eligibility from NMED to EMA for labor and delivery. MMIS will identify any claims for labor and delivery charges for women on NMED and process them for payment with federal funding under EMA.
Example:
Nadia applies for MA and indicates she is pregnant on the application. Nadia is a lawful permanent resident who entered the country after August 22, 1996. She has not been in the U.S. for five years. She is not eligible for federally funded programs due to her immigration status. She is otherwise eligible for MA without a spenddown.
Action:
If Nadia does not have other health coverage, she may be eligible for SCHIP-funded MA (NMED-PC). If she has other health coverage, she may be eligible for state-funded MA (NMED-PX).
Pregnant noncitizens who have an undocumented or nonimmigrant status may be eligible for SCHIP-funded MA (NMED-PC) through the birth month and state-funded MA (NMED-PX) for the postpartum period, or, they may be eligible for EMA for labor and deliver only.
SCHIP-funded MA (NMED-PC) is available through the birth month for pregnant noncitizens with an undocumented or nonimmigrant status if they meet all of the following criteria:
l Meet all MA eligibility criteria other than immigration status.
l Do not have other health insurance. This includes an employer health plan, medical service policy, hospital policy, or HMO coverage.
l Are eligible without a spenddown.
Pregnant noncitizens with an undocumented or nonimmigrant status who:
l Meet the above criteria should be coded in MMIS with eligibility type ”PC” through the birth month, and with eligibility type "PX" for the postpartum period.
l Do not meet the above criteria are ineligible for federally funded, SCHIP-funded, or state-funded MA. These women are only eligible for EMA for labor and delivery, or other conditions that meet the definition of a medical emergency.
Example:
Laris applies for MA and indicates she is pregnant on the application. She is an undocumented noncitizen. Laris is otherwise eligible for MA without a spenddown, but has other health coverage through her husband's employer.
Action:
Since she has other health coverage, Laris is not eligible for SCHIP-funded MA (NMED-PC). Laris may be eligible for EMA to cover labor and delivery when the baby is born.
Note: If she did not have other health coverage, Laris would be eligible for SCHIP-funded MA (NMED-PC) through the birth month and state-funded MA (NMED-PX) for the postpartum period.
There is no difference in eligibility and benefits for enrollees in federally funded, SCHIP-funded, or state-funded MA. These designations are coded by the worker so the appropriate funding sources may be accessed. See Medical Assistance Eligibility for Pregnant Women for a summary of system coding for pregnant women.
Do not use the Systematic Alien Verification for Entitlements (SAVE) system for women who are eligible for NMED as undocumented or nonimmigrant pregnant women.
Residency (standard guidelines)
Apply state residency requirements to all pregnant women.
Example:
Marlene is six months pregnant and has been MA-eligible for four months. She reports she is moving to Utah permanently.
Action:
Close MA effective the first month for which you can give ten-day notice following the move.
There may be insurance barriers for some pregnant noncitizens. See information above about SCHIP-funded MA.
Require pregnant women to cooperate with third party liability (TPL) and tort liability requirements as a condition of initial and continued eligibility.
Note: Do not consider leaving employment or taking a maternity leave as non-cooperation if the insurance is no longer available.
Example:
Greta is pregnant and applies for MA. She has insurance through her job which will cover some of the pregnancy costs. The insurance is determined to be cost effective. The county must pay the premiums and Greta must keep the insurance as long as it remains cost effective and available to her.
Action:
Close or deny MA if Greta refuses to cooperate with the cost effectiveness determination or with keeping the cost effective coverage in effect.
Policies covering a pregnant woman's maternity care are considered cost effective by the Benefit Recovery Section (BRS) for the pregnant woman and any other MA-eligible household members covered by the same premium. These policies do not require further review.
Exception: SCHIP-funded MA does not have cost effective insurance requirements and cannot pay cost effective insurance premiums. Pregnant women who are potentially eligible for SCHIP-funded MA are not required to provide information about or pursue other health coverage that may be available to them through an employer or other means.
Household Composition (standard guidelines)
Consider a pregnant woman to be a household of two. Follow standard MA guidelines to add other members to her household size.
Exception: If a woman verifies she is expecting more than one child, count the number of all unborn children in her household size.
Example:
Millie and her eight-year-old son Milo are applying for MA. Millie verifies that she is expecting twins.
Action:
Consider Millie and Milo to each have a household size of four.
Use Method A for income.
Asset Guidelines (standard guidelines)
There is no asset limit for pregnant women through the 60-day postpartum period.
Income standard is 275% FPG.
Note: Once you approve verified eligibility for a pregnant woman who meets this income standard, do not act on increases in income through the end of the 60-day postpartum period .
Apply the work expense deduction for pregnant women and infants. If income exceeds 275% FPG after the deduction is applied, see Spenddowns below.
If income exceeds 275% FPG (standard C) after allowing the work expense deduction as noted above, pregnant women may be eligible by spending down to 100% FPG (standard E). Redetermine net income for these women using the:
l 17% earned income disregard.
If the woman is determined eligible with a spenddown, she must continue to meet the spenddown to remain eligible through the end of the 60-day postpartum period. Consider a monthly spenddown if the woman cannot meet a six-month spenddown.
If the woman is determined eligible with a monthly spenddown, use whatever standard is appropriate for each month depending on her income.
l First, compare the monthly income to standard C (275% FPG) for each month. If the income is under standard C, there is no spenddown for that month.
l If the income for the month is over standard C, then the woman must meet a spenddown using standard E (100%).
For either a six-month or monthly spenddown, do not increase the spenddown due to increases in income. However, decreases in income or changes in earned income disregards or household composition may affect the spenddown amount.
Note: Do not consider fluctuating income such as a three- or five-paycheck month to be an income change when determining if the income has increased.
Example:
Julia reports on her application for MA that she is pregnant, and includes all required verifications. Julia’s income for the six-month certification period of June through November exceeds 275% FPG (standard C) for a household of two. After the pregnant women and infants work expense deduction is applied, Julia's income is still above 275% FPG for the six-month period.
Action:
Redetermine Julia’s income using 100% FPG (standard E) and apply the 17% earned income disregard and the dependent care and child support deductions.
Julia is eligible for MA with a six-month spenddown. Then, in September, she reports that she has reduced her hours at work due to the pregnancy.
Action:
Recalculate Julia’s income based on the new information and reduce her spenddown amount accordingly.
Note: If Julia had reported an increase in income, there would have been no changes to the budget. Increases in income are not acted upon for pregnant women once they are enrolled.
Covered Services (Prepaid MHCP Manual)
Pregnant women do not have co-payments or dental limits.
Pregnant women who also meet a disabled basis of eligibility may choose to be excluded from managed care enrollment even if they are currently eligible under the Pregnant Women basis. Complete the necessary system coding and case note to document this limited disability exclusion. See the Prepaid Minnesota Health Care Programs Manual, section 04.03.01, for more information.
Do not require a pregnant woman to cooperate with any paternity or medical support matter for any child in her household during the pregnancy or 60-day postpartum period.
Example:
Maureen and her son Patrick are eligible for MA. On May 15, she reports she is pregnant and due in November. On June 10, the child support officer reports that she is not cooperating in establishing paternity for Patrick.
Action:
Do not terminate Maureen's MA for non-cooperation. At the end of the 60-day postpartum period, she must cooperate with the child support office if she wants continued MA for herself.
Eligibility continues through the last day of the month in which the 60-day postpartum period ends if a woman applied before or after the end of her pregnancy and was eligible without a spenddown for the budget period.
Note: The pregnancy can end with birth, abortion, miscarriage, or stillbirth.
Redetermine MA eligibility prior to the end of the 60-day postpartum period. All women who wish to continue MA coverage must update their income and asset information and submit any required verifications. See MA Pregnant Woman Renewal Requirements for more information about the redetermination process.
After completing the redetermination:
l If eligibility exists under another basis, leave MA open under the new basis.
l If eligibility does not exist under another basis, close MA on the last day of the month in which the 60-day postpartum period ends.
If the new mother and auto newborn are the only household members enrolled in MA/GAMC:
l Use the current certification period if a renewal has been completed within the past six months.
l Begin a new certification period if a renewal has not been completed within the past six months.
If other household members are enrolled in MA/GAMC, use the same certification period for the new mother and auto newborn.
Redetermine eligibility for MA for GAMC enrollees who become pregnant; pregnancy-related services are not covered under GAMC. Also redetermine eligibility under the Pregnant Women basis for MA enrollees who are eligible under another basis. See Enrollee Becomes Pregnant.
If a woman who is enrolled in MA for Breast/Cervical Cancer (MA-BC) becomes pregnant and is:
l Eligible under a pregnant woman basis without a spenddown, she must change to the pregnant woman basis. At the end of the 60-day postpartum period, redetermine her eligibility for MA-BC.
l Eligible under a pregnant woman basis with a spenddown, she may choose to remain eligible with an MA-BC basis.
Also consider MinnesotaCare for Pregnant Women.