Pregnancy Medical

Created on: 
Aug 11 2017

Family Planning Service Only (P05)

Online Processing

See ACES Screens and Online pages for an example of pages or screens used in this chapter.

What is the Family Planning Service Only (P05) medical program?

P05 medical provides coverage for family planning services for women who were:

  • Eligible for medical coverage on the last day of their pregnancy, or
  • Who were approved retroactive pregnancy medical.

For more information regarding P05 medical, see:

How long is the Family Planning Service Only (P05) certification period?

The P05 certification period is ten months following the client's sixty-day post pregnancy coverage.

When does Family Planning Service Only (P05) medical begin?

The following pregnancy medical assistance units trickle to P05 medical at the end of their regular certification periods:

  • MAGI - Pregnancy - Federal (N03)
  • MAGI - Pregnancy State (N23)
  • Medically Needy Pregnancy (P99)
NOTE: All individuals who receive Washington Apple Health (WAH) pregnancy coverage are auto-opened on P05 through the end of the twelve-month post-partum period.  This occurs for eligible individual(s) whose Modified Adjusted Gross Income (MAGI) coverage is closed and they are not active on any other Categorically Needy (CN) coverage.

What if the client reports a new pregnancy during the family planning extension?

If a client reports a pregnancy during the family planning extension, refer the client the www.wahealthplanfinder.org to apply for pregnancy medical coverage.

Online Processing

What happens if Family Planning Service Only (P05) is not auto-opened at the end of the pregnancy medical certification period?

If P05 medical is not automatically opened at the end of the pregnancy medical certification period, then users should screen in a new P05 Assistance Unit (AU). For more information on how to screen an AU, see Screening an Application. 

 

See ACES Screens and Online pages for an example of pages or screens used in this chapter.

Medically Needy Pregnancy Medical with Spenddown (P99)

Created on: 
Nov 13 2019

Online Processing

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Who processes P99 (Medically Needy Pregnancy Medical with Spenddown) Assistance Units (AUs)

All P99 AUs are processed by Health Care Authority (HCA) users and assigned to Region 9 in one of the following MAGI CSO’s:

  • 181- Houses MAGI AUs that belong to Region 1 geographical/zip catchment
  • 182- Houses MAGI AUs that belong to Region 2 geographical/zip catchment
  • 183- Houses MAGI AUs that belong to Region 3 geographical/zip catchment

Who is eligible to receive P99 (Medically Needy Pregnancy Medical with Spenddown)?

Pregnant woman who meet the criteria in Apple Health Eligibility Manual - WAC 182-505-0115 Washington apple health - Eligibility for pregnant women are eligible for P99 medical. 

How long is the Medically Needy Pregnancy Medical with Spenddown (P99) certification period?

P99 medical is certified to the end of the final month of the base period as described in the Apple Health eligibility manual – WAC 182-505-0115 Washington Apple Health - Eligibility for pregnant women

The base period should be through the end of the final month of pregnancy, not to exceed six months. For additional information, see: 

Can a client receive P99 (Medically Needy Pregnancy with Spenddown) medical coverage while incarcerated?

When a client is active or approved under some medical coverage groups while incarcerated, they can still be eligible to receive medical assistance in a suspended status. For more information, see Suspended Medical – State Bill (SB 6430).

When is a pregnant woman not eligible for the post-partum medical extension?

If an application is not submitted and eligibility determined prior to the end of the pregnancy, the pregnant woman is not eligible for the two-month post-partum medical extension, even if medical care is authorized retroactively to cover the pregnancy.

A client can apply for medical assistance to cover the expense of the birth of the baby even after the baby is born.

When a woman is not eligible for the post-partum extension, Family Planning (P05) coverage begins the first of the month following the month the pregnancy ended.

Online Processing

How do I screen a P99 (Medically Needy Pregnancy Medical with Spenddown) Assistance Unit (AU)?

To screen P99 medical, take the following steps:

  1. Follow the instructions in How do I screen an application for a client?
  • On the Programs page, select the checkbox next to Medical.
  • On the Finalize page, click Specify Program.
  • On the Finalize - Program Details page select the following:
    • Program drop down - Select Medical Assistance (MA).
    • Medical Coverage Group drop down - Select Medically Needy Pregnancy (P99).
    • ​​Program Type drop down - Select the appropriate option from the list.

How do I process a pending P99 (Medically Needy Pregnancy Medical with Spenddown) Assistance Unit (AU)?

To process a pending P99 AU, follow the steps in the Process Application Months and Finalize Application chapters.

For additional information, for information on the Spenddown process, see Apple Health eligibility manual – Apple Health for the Medically Needy and Spenddown overview.

How do I enter Spenddown medical expenses for a P99 (Medically Needy Pregnancy Medical with Spenddown) Assistance Unit in MA - Spenddown (M) status?

To enter medical expenses to meet the client’s Spenddown liability on a P99 AU in MA Spenddown (M) status, see Spenddown - Processing - How do I enter medical expenses? 

After the expenses have been added, follow the steps in Spenddown - Processing - How do I assign medical expenses and authorize Spenddown? 

What if the pregnancy ends before the original due date?

When the pregnancy ends in a month prior to the original due date entered on the Client Details page, take the following steps:

  1. In the Change of Circumstances section on the Case Actions page, use the drop down menu to select the appropriate Benefit Month and click Start Changes.
  2. On the Client Details page, change the pregnancy information to reflect the actual date the pregnancy ended.
  3. Select Review on the Navigation tree. ACES rechecks all AU/client data for errors and required verifications. If no other updates are required, select Eligibility on the Navigation tree.
  4. On the Eligibility page, click the Details link, review the data on the Eligibility Details page and click Confirm Benefits.
  5. On the Eligibility page, click Commit Changes.

What if the pregnancy ends prior to the original due date or prior to the certification end date?

If the Spenddown is met prior to the birth of the baby and the baby is born early, the Medically Needy Pregnancy Medical with Spenddown (P99) Assistance Unit (AU) certification period cannot be shortened.

Check the certification period, and if the certification period ends after the two months post-partum period, screen a new P99 Assistance Unit (AU) with the correct due date using the steps in Online processing - How do I screen a Medical Needy Pregnancy Medical with Spenddown (P99) Assistance Unit (AU)? 

What if the pregnancy ends after the original due date or during the post-partum extension?

When the pregnancy ends in a month after the original due date entered on the Client Details page, take the following steps:

  1. Close the current AssistanceAU with a 500 level reason code. For additional information, see Online processing - How do I deny or terminate a case with a 500 level Reason Code?.
  2. Screen and process a new P99 AU with the correct due date.
NOTE: A P99 AU in MA Spenddown (M) status does not allow you to initiate a review. If the P99 is in Active (A) status, displays Spenddown Period Expires in a Future Month.

When do P05 (Family Planning Services) begin?

Medically Needy Pregnancy Medical with Spenddown (P99) does not trickle to a Family Planning (P05) Assistance Unit (AU). If the woman does not meet Spenddown until the baby is born, she is considered eligible for family planning services. Family planning begins after the post-partum period.

Set a tickle to screen a P05 AU for the month after the post-partum period ends. For additional information, see Add a Program if the P99 is still active or see Screening an Application if the AU has closed. 

 

See ACES Screens and Online Pages for an example of pages or screens used in this chapter.

Modified Adjusted Gross Income (MAGI) Post-Partum Coverage

Created on: 
Jun 30 2022

What is Modified Adjusted Gross Income (MAGI) Postpartum Coverage?

Postpartum coverage for MAGI medical recipients includes the following programs:

After-Pregnancy Coverage (N04) is postpartum coverage through the end of the 12th month after the pregnancy end date. To be eligible for this program, a client either: 

  • Received Pregnant Federal (N03) or Pregnancy State (N23) medical in the month their pregnancy ended, or
  • Received Categorically Needy (CN) or Medically Needy (MN) coverage at any time during their pregnancy and they currently meet eligibility requirements for coverage from a higher priority CN program.

Expanded After-Pregnancy Coverage (N07) is postpartum coverage through the end of the 12th month after the pregnancy end date. To be eligible for this program, a client:

  • Didn't receive CN or MN coverage at any time during their pregnancy, 
  • Met the non-financial eligibility requirements of the N03 or N23 program, and
  • Their income is less than or equal to the N03 or N23 income standard. 

State After-Pregnancy Coverage (N24) is state funded postpartum coverage through the end of the 12th month after the pregnancy end date. To be eligible for this program, a client either: 

  • Received medical on an N03 or N23 program in the month their pregnancy ended, or
  • Received CN or MN coverage at any time during their pregnancy and they don't currently meet eligibility requirements for coverage from a higher priority CN program. 

State Expanded After-Pregnancy Coverage (N27) is state funded postpartum coverage through the end of the 12th month after the pregnancy end date. To be eligible for this program, a client:

  • Didn't receive CN or MN coverage at any time during their pregnancy, 
  • Met the non-financial eligibility requirements of the N03 or N23 program, and
  • Their income is less than or equal to the N03 or N23 income standard.

For more information regarding After-Pregnancy Coverage programs, see the Apple Health eligibility manual - After-Pregnancy Coverage.

When does After-Pregnancy Coverage begin?

Individuals are eligible for postpartum coverage under the After-Pregnancy Coverage  program through the end of the 12th month after their pregnancy ends, and either of the following conditions are true:

  • They were active on Pregnant - Federal (N03) or Pregnancy - State (N23) at the time their pregnancy ended, or
  • They received Categorically Needy (CN) or Medically Needy (MN) coverage at any time during their pregnancy and they do not currently meet eligibility requirements for coverage from a higher priority CN program.

There are no income or resource limits for After-Pregnancy Coverage.

When does Expanded After-Pregnancy Coverage begin?

Individuals are eligible for postpartum coverage from the new Expanded After-Pregnancy program through the end of the 12th month after their pregnancy ends when all of the following conditions are true:

  • They had a pregnancy end within the last 12 months.
  • They did not receive Categorically Needy (CN) or Medically Needy (MN) coverage at any time during their pregnancy.
  • They meet the non-financial eligibility requirements of the N03 or N23 program (e.g., residency, citizenship). 
    • Having to have a current pregnancy is excluded from this condition.
  • At the time of the initial eligibility determination, their income is less than or equal to the N03 or N23 income standard.

Once an individual has have been determined eligible for postpartum coverage, the coverage is continuous through the end of the 12th month from the pregnancy end date as long as they continue to meet non-financial eligibility requirements. Income changes during the postpartum certification period don't affect eligibility.

What if the client reports a new pregnancy during the After-Pregnancy coverage period?

If an individual meets the eligibility requirements for coverage from a higher priority coverage group than the After-Pregnancy program, then that program will provide their postpartum coverage. If this eligibility ends, then they are eligible to receive coverage under the After-Pregnancy program for the remainder of their 12-month post-partum coverage period.