Title 42 Subsection 435.915, states that eligibility for prior quarter 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 prior quarter (PQ) coverage for 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 may continue through the postpartum period despite any increases in income.
The begin date for prior quarter 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 prior quarter. If time period requested exceeds 40 weeks, this information is questionable and verification should be requested.
EXAMPLE: Ms. T applies December 10th; prior quarter 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 prior quarter can be explored.
Determine income for prior quarter 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 prior quarter 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 prior quarter months
If the participant requests coverage for all three prior quarter months and income for the first month of the prior quarter 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; prior quarter 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 prior quarter months and income for the first month of the prior quarter exceeds the MPW income maximum, then explore eligibility for the following month(s).
EXAMPLE: Ms. X applies February 24th and requests prior quarter. Prior quarter 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 prior quarter 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 prior quarter 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 prior quarter is determined individually. Therefore, a participant may be found eligible for different LOCs in different months of the prior quarter 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 prior quarter 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.