Title 42 Subsection 435.915, states that eligibility for prior quarter (PQ) coverage may be effective on the first day of a month that an individual received medical services and was eligible at any time during that month. The eligibility for PQ months should be treated as if the person had applied in that month.
When a participant requests PQ coverage for MO HealthNet for Pregnant Women (MPW), she must meet all eligibility factors including pregnancy. Eligibility is determined for each month separately; coverage begins on the first day of the month in which she became eligible. Once eligible, the coverage will continue through the postpartum period despite any increases in income.
The begin date for PQ coverage can be no earlier than the first day of the third month prior to the month of application.
NOTE: The participant statement should indicate the estimated due date to determine if she will be eligible for the entire PQ. If time period requested exceeds 40 weeks, this information is questionable; request verification.
EXAMPLE: Ms. T applies December 10th; PQ coverage can be explored starting with September 1st. Ms. T attests that her due date is in July. It is appropriate to request further verification to determine what months of PQ can be explored.
Determine income for PQ months using the same methodology as the month of application. These guidelines are in manual section 1805.030.00 Modified Adjusted Gross Income (MAGI) Methodology.
When completing income budget(s) for PQ months, use reasonable compatibility (RC) to confirm the self-attestation of income in each month. Please refer to manual section 1805.030.15 Reasonable Compatibility for information on RC.
When the participant requests coverage for all three PQ months
If the participant requests coverage for all three PQ months and income for the first month of the PQ does not exceed the MPW income maximum the woman is eligible for all months of PQ if all other eligibility factors are met.
EXAMPLE: Ms. G applies/requests coverage for the current month and all three PQ months on September 15th; PQ coverage can be explored starting with June 1st. Her income in June is less than the MPW income maximum. There is no need to explore income for July and August as once eligible for MPW coverage continues through her post-partum period.
If the participant has requested coverage for all three PQ months and income for the first month of the PQ exceeds the MPW income maximum, then explore eligibility for the following month(s).
EXAMPLE: Ms. X applies February 24th and requests PQ. PQ coverage can be explored starting with November 1st. Her income in November is more than the MPW income maximum. Explore December eligibility. If she is over income for December, explore January eligibility.
EXAMPLE: Ms. K applies November 12 with a due date of January 13 and requests coverage for all three PQ months. Her income varies from month to month. Her August income was $3000, her September income was $1000 and her October income was $2500, and her November income is $1000. Income will be budgeted as income received in each PQ month. She is over income for August, but is eligible on all factors in September. Approve coverage beginning September 1st and ongoing.
EXAMPLE: Ms. W applies October 4 and requests coverage for all three PQ months. Her estimated due date is June 14. Based on the statement, the beginning date of pregnancy is September 14. The PQ coverage can begin no earlier than September 1.
There is no need for the level of care (LOC) to remain the same throughout the coverage period. Eligibility for each month of PQ is determined individually. Therefore, a participant may be found eligible for different LOCs in different months of the PQ and for ongoing coverage.
EXAMPLE: Ms. M requests coverage and has medical bills for all three PQ months. She is eligible for an LOC of ME 18 in month one, over income in month two, an LOC of ME 45 in month three and ME 18 ongoing. Ms. M should be given ME 18 in month two to continue her eligibility for MPW into month three. Month three and ongoing provide her with continuous coverage even though they are different LOCs.
When the participant does not request coverage for all three PQ months
Because eligibility for each month of prior quarter is determined separately, a participant who requests and is eligible for MPW in the prior quarter may receive specific months of coverage based on eligibility and the months requested.
EXAMPLE: Ms. G requests coverage and has medical bills for month one in the PQ. She applies for current/ongoing coverage for current and future medical expenses, and she applies for month one in the PQ because of bills she received in that month. She is found eligible and is approved for PQ month one, and the month of application & ongoing.
If you cannot verify a need for coverage in the PQ period, evaluate for coverage beginning in month of application.
MPW coverage continues into application/ongoing months
Once determined eligible, MPW coverage may continue through the postpartum period.
EXAMPLE: Ms. A applies for MPW after the birth of her child and requests PQ coverage. She is eligible for ME 18 in the PQ, but her income exceeds the income maximum in the application month. Her coverage begins in the PQ and can continue through the end of the month in which the pregnancy terminated.
MPW in PQ; SMHB in application month
Once approved for MPW in a PQ month, coverage cannot switch to SMHB in the application month or in any ongoing month, through post-partum months.
Use the level of care in the most recent PQ month to determine the level of care in the application month and ongoing.
EXAMPLE: Mrs. Q applied on December 20th and requested ongoing coverage and PQ benefits for all 3 months. In September and October, she is eligible for MPW-MHF; in November she is eligible for MPW-POV. Her income in the application month reflects eligibility for SMHB; however, her coverage is locked-in at MPW-POV beginning in November and ongoing.