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Effective: December 1, 2006 |
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03.25.05ar1 - Medical Assistance (MA) for Pregnant Women (Archive) |
Archived: February 1, 2008 |
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 state-funded MA (program NMED) even if they have an undocumented or non-immigrant status. This basis is potentially available from the first day of the month of conception through the last day of the month in which the 60-day postpartum period ends.
Eligibility factors are listed below with any information that is unique for this group. Links to standard program guidelines are included as well.
Citizenship/Immigration Status.
Insurance and Benefit Recovery.
Relationship to Other Groups/Bases.
Other Groups/Bases to Consider.
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, such as some hospitals and clinics.
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 gives birth to Billy on September 17.
l For the six-month budget period that includes September, she has a spenddown that she is unable to meet.
l However, her anticipated income for the six-month budget period that begins in October is under the pregnant woman income standard for the postpartum months (October and November).
Action:
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 by 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 non-immigrant status and eligible for NMED are not required to provide SSNs.
Pregnant noncitizens who do not qualify for federally funded MA because of their immigration status (including undocumented and non-immigrant) may be eligible for state-funded MA (program NMED) through the 60-day postpartum period. NMED will cover prenatal and postpartum care.
Note: Although Emergency Medical Assistance (EMA) covers labor and delivery for eligible noncitizens, 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.
SCHIP federal funding may be available for pregnant noncitizens who are eligible for NMED if they meet all of the following criteria:
l Do not have an undocumented or non-immigrant 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 who meet the above criteria should be coded in MMIS with eligibility type ”r;PC” instead of ”r;PX.”
Note: There is no difference in eligibility and benefits for the enrollee. This designation is coded by the worker so SCHIP federal funds may be accessed.
See Bulletin #05-21-09, attachment B, 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 non-immigrant pregnant women.
Residency (standard guidelines)
Apply state residency requirements to pregnant women, including those with an undocumented or non-immigrant status.
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 federal funding.
Note: Pregnant women with an undocumented or non-immigrant status who have other health insurance may be eligible only for EMA for labor/delivery or other conditions that meet the definition of a medical emergency.
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:
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 consider changes in income through the end of the 60-day postpartum period.
Work expense deduction for pregnant women and infants.
If income exceeds 275% FPG after allowing the work expense deduction, pregnant women may be eligible by spending down to 100% FPG. Redetermine net income for these women using the:
l 17% earned income disregard.
Note: If the woman was eligible with a spenddown, she must continue to meet the spenddown to remain eligible through the end of the 60-day postpartum period. 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.
Covered Services (standard guidelines)
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. The worker must 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.
If a woman applied before or after the end of her pregnancy and was eligible without a spenddown for the budget period, her eligibility continues through the last day of the month in which the 60-day postpartum period ends.
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.
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.
Also consider MinnesotaCare for Pregnant Women.