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Effective: June 1, 2011 |
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03.25.05ar7 - Medical Assistance (MA) for Pregnant Women (Archive) |
Archived: June 1, 2012 |
All pregnant women have a basis of eligibility for MA. However, the MA funding source for pregnant women is dependent on the individual’s citizenship or immigration status. Pregnant women who are citizens or lawfully present noncitizens may qualify for federally funded MA. Undocumented pregnant women and some nonimmigrant pregnant women who are not eligible for federally funded MA solely due to their immigration status may be eligible for MA funded by the Children's Health Insurance Program (CHIP) (major program NM, eligibility type PC). 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.
Pregnancy must be verified by a physician, registered nurse, licensed nurse midwife, certified nurse practitioner, or physician’s assistant. Do not require additional verification if the pregnancy has already been verified for MinnesotaCare or a cash assistance program.
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 due dates reported on the application. Estimate the date of conception using the reported due date. The estimated date of conception is nine months prior to the reported due date. Contact the woman to obtain her due date if she did not report it on the application. Use an estimated date of delivery while waiting to receive verification if unable to reach the client.
Example:
Pa applies for health care on March 15. She reports on the application that she is pregnant with a due date of October 21.
Action:
Estimate Pa’s date of conception as January 21, nine months prior to the due date.
2. Approve MA under a pregnant woman basis if she meets all other eligibility requirements and request verification of pregnancy.
3. Send a Proof of Pregnancy (DHS-3236) form to the client. The client must submit verification of pregnancy within 60 days of the request.
Note: Accept another form of verification as long as it verifies the woman is pregnant and includes the estimated date of conception. The provider’s signature is not required. Obtain a release of information to contact the provider if the verification is incomplete.
n If the client fails to submit verification within 30 days of the request, send a second notice informing her she will lose pregnant woman status if she does not submit verification of pregnancy within 30 days.
n Determine whether the client is eligible under another basis if she does not submit verification within 30 days of the second notice.
Note: If the client later submits the verification, approve pregnant woman status back to the date of conception or the effective date of coverage, whichever is later.
Social Security Number (standard guidelines)
Pregnant women who are noncitizens with an undocumented or nonimmigrant status who qualify for CHIP-funded MA (NM/PC) or Emergency Medical Assistance (EMA) for the inpatient stay related to labor and delivery are not required to provide SSNs.
Pregnant women may qualify for MA with federal financial participation (FFP) or CHIP-funded MA.
State-funded MA only applies to pregnant women who are ineligible for MA with FFP and CHIP-funded MA, but who receive services at the Center for Victims of Torture.
Pregnant women who are U.S. citizens or lawfully present noncitizens who meet Minnesota residency requirements and all other eligibility criteria may be eligible for MA for the duration of the pregnancy and the 60-day postpartum period.
Example:
Mai applies for MA and indicates on her application that she is pregnant. She is a noncitizen with an immigration status of Lawful Permanent Resident. She meets all MA eligibility criteria.
Action:
Approve MA with FFP (MA/PX) for Mai. She is a pregnant woman and a lawfully present noncitizen.
Undocumented pregnant women and some nonimmigrants who meet Minnesota residency requirements may be eligible for CHIP-funded MA (NM/PC) for the duration of the pregnancy and the 60-day postpartum period. To qualify for CHIP-funded MA, they must 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 Have income at or below the 275% FPG income standard. There is no spenddown eligibility under CHIP-funded MA.
Access to or the availability of other health insurance, such as through an employer plan, is not a barrier to CHIP-funded MA. An applicant or enrollee is ineligible for CHIP-funded MA only if she actually has other health coverage.
Pregnant women who do not qualify for CHIP-funded MA due to other health coverage or income above the 275% FPG income standard may be eligible for EMA for the inpatient stay related to labor and delivery, or for other conditions that meet the definition of a medical emergency.
Example:
Uba applies for MA and indicates she is pregnant on the application. She is an undocumented noncitizen. She does not have other health insurance. She meets all other MA eligibility criteria.
Action:
Approve CHIP-funded MA (NM/PC) for Uba. She does not have to provide a Social Security Number to qualify. She is eligible for CHIP-funded MA for the duration of her pregnancy and the 60-day postpartum period.
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 CHIP-funded MA. Laris may be eligible for EMA to cover the inpatient stay related to labor and delivery when the baby is born.
Note: If she did not have other health coverage, Laris would be eligible for CHIP-funded MA through the 60-day postpartum period.
See Medical Assistance Immigration Status and Eligibility Table for a summary of system coding for noncitizen pregnant women.
Do not use the Systematic Alien Verification for Entitlements (SAVE) system for undocumented or nonimmigrant pregnant women who are eligible for CHIP-funded MA or EMA.
For system codes see POLI/TEMP TE13.047 (Health Care for Noncitizen 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 CHIP-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: CHIP-funded MA does not have cost effective insurance requirements and cannot pay cost effective insurance premiums. Pregnant women who are potentially eligible for CHIP-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 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.
Noncitizen pregnant women are not subject to sponsor deeming for the duration of their pregnancy and 60-day postpartum period. Do not apply sponsor deeming when determining eligibility for noncitizen pregnant women applying for or enrolled in MA. Do not require a copy of the Affidavit of Support or verification of sponsor income or assets when determining MA eligibility for pregnant women.
Sponsor deeming requirements apply effective the month following the end of the 60-day postpartum period. Request the Affidavit of Support and verification of sponsor’s income and assets when redetermining eligibility prior to the end of the 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 who qualify for MA with FFP 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.
Pregnant women with an undocumented or nonimmigrant immigration status must have income at or below the 275% FPG standard to qualify for CHIP-funded MA. There is no spenddown eligibility under CHIP-funded MA.
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:
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, use the same certification period for the new mother and auto newborn.
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.