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Apple Health for Pregnant Women

Revised Date:

December 11, 2014

WAC 182-505-0115 Washington apple health -- Eligibility for pregnant women.

Effective August 29, 2014.

A pregnant woman is eligible for the Washington apple health (WAH) for pregnant women program if she:
1. Meets citizenship or immigration status under WAC 182-503-0535;
2. Meets Social Security number requirements under WAC 182-503-0115;
3. Meets Washington state residency requirements under WAC 182-503-0520 and 182-503-0525; and
4. Has countable income at or below the limit described in:
  1. WAC 182-505-0100 to be eligible for categorically needy (CN) coverage; or
  2. WAC 182-505-0100 to be eligible for medically needy (MN) coverage. MN coverage begins when the pregnant woman meets any required spenddown liability as described in WAC 182-519-0110.
A noncitizen pregnant woman who does not need to meet the requirements in subsection (1)(a) or (b) of this section to be eligible for WAH and receives either CN or MN coverage based upon her countable income as described in subsection (1)(d) of this section.
The assignment of medical support rights as described in WAC 182-503-0540 do not apply to pregnant women.
A woman who was eligible for and received coverage under any WAH program on the last day of pregnancy is eligible for extended medical coverage for postpartum care for a minimum of sixty days from the end of her pregnancy. This includes women who meet an MN spenddown liability with expenses incurred no later than the date the pregnancy ends. This extension continues through the end of the month in which the sixtieth day falls.
All women approved for WAH pregnancy coverage at any time are eligible for family planning services for twelve months after the pregnancy ends.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying Information

First Steps
1. First Steps is the commonly used term for Maternity Support Services. It is a package of services for pregnant women who are eligible for Apple Health. Sometimes the pregnant woman’s health care coverage is also referred to as First Steps. Effective January 1, 2015, First Steps referrals are completed behind the scenes through the following process:
  1. Pregnant women enrolled in a managed care plan are informed of the First Steps program through their Managed Care Organization (MCO). The MCO sends the HCA First Steps program manager at HCA a list of all the newly identified pregnant women.
  2. Pregnant women who are not enrolled in a managed care plan are identified through ProviderOne.
  3. The First Steps program manager sends the lists from i and ii to the First Steps providers.
Household size:
1. Consider the unborn child(ren) when determining the household size. Add one person for each unborn. This applies to all Apple Health programs.
Income:
1. Pregnant women with income over the MAGI standard of 198% FPL who are enrolled in a Qualified Health Plan (QHP) prior to becoming pregnant can choose between the medically needy program and purchasing health care coverage through a QHP.
Resources:
1. There is no resource standard for MN (P99).
Continuous Eligibility:
1. Apple Health pregnancy coverage has continuous eligibility. Changes in income do not affect Apple Health coverage for pregnant Women during the certification period.
2. Changes in income are considered prior to the spenddown being met for MN (P99) coverage.
Pregnancy Verification:
1. Accept self-attestation for pregnancy and estimated due date (EDD)
2. The date the pregnancy is scheduled to end is the EDD.
Applications made after the pregnancy ends:
1. The pregnant woman is not eligible for the two-month postpartum medical extension, when medical care is authorized retroactively to cover the pregnancy; and
2. The pregnant woman is eligible for the twelve-month medical extension for family planning services, even if she is determined eligible retroactively to cover the pregnancy after the pregnancy ends.
Case Pending Spenddown:
1. When a pregnant woman applies for medical before the baby is born but does not meet spenddown until the baby is born, the woman is considered eligible for Apple Health coverage at the time of the baby’s birth. Therefore, the woman is eligible for:
  1. The extended postpartum care: and
  2. Family planning services.
Medicare Eligible Pregnant Women:

Women who are receiving or eligible for Medicare and become pregnant may be eligible for Apple Health if her income is below the standard of 198% FPL.

Worker Responsibilities

MN (P99) VERSUS QHP – PROCESSED BY MEDS STAFF
Pregnant women are identified through a barcode report run by MEDS staff.
1. Send a letter through Healthplanfinder (HPF) offering medically needy (MN) coverage by meeting a spenddown. Included in this letter is the denial text if no response is received.
2. If the pregnant woman responds via phone call:
  1. Ask if she incurs child care costs; pays out child support; and if retroactive coverage is needed;
  2. Process P99 in ACES.
3. If the pregnant woman responds via mail:
  1. Process P99 in ACES.
End of the pregnancy:
1. For MAGI, click on the report a change link in the Healthplanfinder and update the pregnancy end date to the date the pregnancy ended.
2. For P99, if the pregnancy ends before the expected due date through birth, miscarriage, or termination, correct the estimated date of delivery on the DEM1 Screen in ACES to ensure a timely program change to family planning services (P05).
  1. Adjust the review date to ensure the woman gets additional CN coverage if the pregnancy ends in a month later than the expected due date.
Newborn Medical Coverage:

Note: It is important to add the newborn to Apple Health for Newborns (N10) as soon as possible after birth, so the baby has its own client identification number. This can avoid coverage problems for the baby.

If the mother is served fee-for-service on the date of the baby's birth, a newborn is covered by Medicaid fee-for-service under the mother's client ID through the month that includes the baby's 60th day of life.
Managed care organizations (MCOs, Healthy Options) will only cover a newborn on the mother’s client ID up to a maximum of 21 days after the birth of the baby. After that, a newborn must have his or her own client identification number, or the only medical coverage the newborn receives is fee-for-service, up through the month that includes the baby’s 60th day of life, or until the newborn is assigned his or her own client ID number, whichever is earlier.
Once the newborn has been issued his or her own client ID number, the newborn cannot use the mother's client ID. Individuals who have questions regarding their eligibility for MAGI-based medical assistance should call the Medical Eligibility Determination Service at the Health Care Authority at 855-923-9357. Individuals who have questions about applying online for MAGI-based medical assistance should call the Health Benefit Exchange at 855-923-4633.

WAC 182-505-0117 Washington apple health -- Eligibility for pregnant minors.

Effective November 7, 2014.

For the purposes of this rule, "minor" means a person under the age of nineteen.
A pregnant minor who meets Washington state residency requirements under WAC 182-503-0520 and 182-503-0525 is eligible for the Washington apple health (WAH) for kids program.
The medical assistance unit (MAU) of a pregnant minor is the pregnant minor.
There are no income standards and no resource tests for a pregnant minor to be eligible for WAH for kids.
To ensure reimbursement from the U.S. Department of Health and Human Services, every pregnant minor applicant for WAH for kids must provide her Social Security number unless she is exempt under WAC 182-503-0515 and provide her citizenship or immigration status. The immigration status of a pregnant minor who is an undocumented alien (see WAC 182-503-0530) will not be disclosed to any third party.
The assignment of rights as described in WAC 182-503-0540 does not apply to pregnant minors.
A pregnant minor covered by the WAH for kids program will have a one year certification period unless she has her nineteenth birthday during her pregnancy, at which time she will be automatically enrolled in the WAH for pregnant women program. Under the WAH for pregnant women program, her coverage will continue through the end of her pregnancy and she will be eligible for extended medical coverage for postpartum care through the end of the month of the sixtieth day after the end of her pregnancy.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying Information

A pregnant teen in the Washington Apple Health for Pregnant Teens program will receive full scope health care coverage under Apple Health for Kids, with retroactive coverage to the estimated beginning of the pregnancy and with a certification period as follows:

If she remains under age 19 over the course of her pregnancy, she will be given a 1 year certification period.
If she turns 19 before the end of her pregnancy, her coverage will continue through the end of her pregnancy and she will be eligible for postpartum care through the end of the month of the 60th day after the end of her pregnancy.

Any pregnant teen will be eligible for WAH for Pregnant Teens as long as she is:

Under age 19; and
Meets residency requirements under WAC 182-503-0520.

She will be treated as her own assistance unit, with no income or resource limits. As a result, pregnant teens in this program will not need to provide their parents’ income or asset information.

To apply, complete the paper application "Application for Pregnant Teen Health Care Coverage" (Form HCA 14-430) or submit by mail or fax to:

Medical Eligibility Determination Services (MEDS)
P.O. Box 45531
Olympia, WA 98504-5531

Fax: 360-725-1898

WAC 182-505-0120 Washington apple health breast and cervical cancer treatment program for women--Client eligibility.

Effective September 14, 2015

Effective April 1, 2014, a woman is eligible for categorically needy (CN) coverage under the Washington apple health (WAH) breast and cervical cancer treatment program (BCCTP) only when she:
1. Has been screened for breast or cervical cancer under the department of health's breast, cervical, and colon health program (BCCHP);
2. Requires treatment for breast cancer, cervical cancer, or a related precancerous condition;
3. Is under sixty-five years of age;
4. Is not eligible for other WAH-CN coverage, including coverage under the MAGI-based adult group;
5. Is uninsured or does not otherwise have creditable coverage;
6. Meets residency requirements under WAC 182-503-0520;
7. Meets Social Security number requirements under WAC 182-503-0515;
8. Is a U.S. citizen, U.S. national, qualifying American Indian born abroad, or qualified alien under WAC 182-503-0535; and
9. Meets the income standard set by the BCCHP in DOH form 342-031.
The certification period for breast and cervical cancer treatment covered under this section is twelve months, as provided in WAC 182-504-0015. To remain continuously enrolled, the client must renew her eligibility before the certification period ends. Eligibility for BCCTP coverage under subsection (1)(b) of this section continues throughout the course of treatment as certified by the BCCHP. Retroactive coverage may be available under WAC 182-504-0005.

This is a reprint of the official rule as published by the Office of the Code Reviser. If there are previous versions of this rule, they can be found using the Legislative Search page.

Clarifying Information

The Department of Health (DOH) administers and determines eligibility for the CDC-BCCEDP program for the State of Washington through their Breast and Cervical Health Program. This program provides breast and cervical cancer screening services for low-income women. In addition, CDC directly contracts with certain tribal entities for this screening service.
Access to this program is only available through the above channels. When a woman meets the eligibility criteria, prime contractors (via CDC-BCCEDP facilities) fax the DOH 345-214 consent form/application to Medical Eligibility Determination Services (MEDS) eligibility staff to screen, process, and maintain the S30 program in ACES.
Women not eligible for BCCTP due to citizenship or alien status requirements (described in WAC 182-505-0120(2), are eligible for medical coverage under the Alien Emergency Medical Program rules. Women related to the BCCTP Medicaid program who require cancer treatment meet AEM condition criteria.

Note: Although men may be diagnosed with breast cancer, the federal requirements of this Apple Health program limit medical coverage to only women as described in this section.

Worker Responsibilities

When contacted about this program, refer all inquiries to the nearest local DOH/Breast and Cervical Health provider for women requesting screening services for breast and cervical cancer and/or has not yet been diagnosed. The Department of Health website provides a list of screening clinics. At their website, click the appropriate county.

If an application/review is received in the local CSO indicating breast cancer; screen S02, determine eligibility for the SSI-related program and refer her to the local BCCTP provider (insert DOH website).
Send an email to AskMAGI@hca.wa.gov when a woman is active on BCCTP (S30), applies, and is determined eligible for another CN medical program in order to terminate BCCTP (S30) coverage.
If a woman applies in the local CSO and is found eligible for ABD cash assistance, she continues to be eligible for CN coverage, however, not under the BCCTP program. Send an email to AskMAGI@hca.wa.gov to notify MEDS to terminate coverage under the BCCTP program. At incapacity review, determine whether the individual is still receiving the prescribed course of treatment for breast or cervical cancer.