The system will now alert the caseworker to conduct an ex-parte review 30 days in advance of the closing or conversion.  It will also generate a pre-closing review letter prior to the end of the postpartum period.  The system will continue to close or convert MPW recipients to Extended Women's Health Services (EWHS) based on the insured status if other eligibility is not found during the exparte or pre-closing review. 

I. Ex-parte Review

The following reports will be produced 30 days in advance of the end of the 60 days post-partum.

FIM31414-01  MC+ for Pregnant Women Recipient Due to Convert to EWHS Effective (mm/dd/yy)

FIM31415-01  MC+ for Pregnant Women Recipient Losing Eligibility As Postpartum Ending (mm/dd/yy) as Insured

These reports will list all active persons on the case.  Staff must review each individual's possible eligibility under other MC+/Medicaid categories.  Determine eligibility using information from the record and other available records, i.e., Food Stamp or Childcare records, SDX, Bendex, IIVE, IMES, etc.  It is acceptable to switch categories based on the last budget information on file unless the information is questionable.  If eligibility exists under another category, switch to the appropriate category (an application is not needed).  If discontinuing eligibility under one category and approving in another, process both transactions on the same day in order to prevent any disruption in healthcare coverage. 

Upon receipt of report FIM31414-01 staff must explore eligibility for Medical Assistance for Families (MAF) and Custodial Parent.  If eligible, close the MPW case.  As MPW cases are non-date specific, MC+ eligibility will end the last day of the month.  Approve MAF or CP effective with the first of the following month.  Use the IM-33MCC to notify the individual of the change in eligibility. 

Upon receipt of FIM31415-01 staff must explore eligibility for Medical Assistance for Families.   Eligibility for MC+ for custodial parents does not exist since they are insured.  If eligible for MAF, close the MPW.  As a non-date specific case, eligibility will end the last day of the month.  Approve MAF effective with the first of following month.  Use the IM-33MCC to notify the individual of change in eligibility.

II. Pre-Closing Review

A system generated notice of ineligibility for MC+ for Pregnant Women will be sent thirty (30) days in advance of eligibility ending.  There are two (2) versions of the notice, one for recipients who will convert and one for recipients who will close.  The notice will inform the recipient that eligibility for MAF and MC+ for Custodial Parents is being explored.  The notice also informs the recipient of other possible basis for eligibility and serves as the Pre-Closing Review Notice (See attached).  The individual will be allowed ten (10) days to respond.

The letter to the recipient, who does not qualify for EWHS because of insured status, advises the client our records reflect health insurance coverage and if this is incorrect, to notify our office and this could affect their eligibility.  If the client reports the coverage is no longer in effect, update Field 13-03 to reflect uninsured status immediately.  Submit a TPL-1 to DMS notifying them of the change in coverage.

A. No Response from Client:

If eligibility is not established in the ex-parte review and there is no response from the individual indicating any other possible eligibility, allow the case to close or convert to EWHS as appropriate.  A system generated closing or conversion to EWHS letter will be sent (See attached). 

B. Response from Client:

If eligibility is not established in the ex-parte review but the individual responds to the Pre-Closing Review Notice indicating other possible eligibility, register the appropriate application in IAPP.  Allow the current eligibility for the individual to remain open pending the eligibility determination for the other category.  This is done by updating the IMU5 with case action 35 and entering a new date in Field 32 of three months in the future.  This action will prevent the system from closing or converting to EWHS at the end of the original time limit.

If the client notifies the worker of a change in circumstances such as a change in income, re-evaluate eligibility for MAF or CP as appropriate.

No new, signed application from the individual is required to switch categories.  An R(2) application may be required if the client claims pregnancy. If disability or blindness is claimed, use the IM-2D when determining eligibility under Medical Assistance.  Use the IM-1UA (NCP) when determining eligibility under the Non-Custodial Parent program.  One category of coverage should not be stopped before the other category is approved or determined ineligible.

NOTE:  If the individual does not respond to the Pre-Closing Review Notice within ten (10) days, but does respond indicating other possible eligibility prior to the termination of the MPW, follow the same instructions above.  If they respond indicating other possible eligibility after the case is closed treat as a new application.  If the case converted to EHWS, switch categories if other eligibility is established. 

1) Eligibility Established for Another Category

If eligibility is established under another category, close the MPW and approve the other category the same date.  Use the IM-32 to notify the client of approval for MA.  Use the IM-33MCC to notify the client of approval for MC+ for Pregnant Women.  Include the ending date of new post-partum period on the form.  Use the IM-32NCP to notify the client of the switch to Non-custodial parent.  Each notice should include a statement that eligibility no longer exists under MPW because of the sixty (60) days post-partum coverage has been exhausted.

2) Ineligible for Another Category 

MPW Closing Ineligible for EWHS:  If determined ineligible based on reported pregnancy, disability, blindness, change in circumstances or currency of child support payments, send an IM-80MC specifying the reason eligibility for MC+/Medicaid does not exist.  Address the reason for the denial of the new category, the reason for loss of eligibility for MPW and the reason for ineligibility for EWHS.  A separate rejection notice for the new category is not required as the IM-80MC notifies the client of ineligibility for MC+/Medicaid categories and provides appeal rights.  The MPW case should be closed once the IM-80MC expires, as they are insured and the postpartum period has ended.  Use the IM-33MCC to notify the individual of the MPW closing.

MPW Eligible for EWHS:  If determined ineligible for the new category, the appropriate rejection notice should be sent to the individual.  In order for the case to convert to EWHS, correct the ending date in Field 32 to the end of the current month by using case action 35.  This action can be done up to the 2nd to the last working day of the month.  This will allow the case to convert at the end of the month.  A systems generated letter will notify the client of the change to EWHS.

III. Appeals

If a client requests a hearing to appeal the denial of eligibility for other programs, allow the MC+ for Pregnant Women case to remain open pending a decision.  Use case action 35 to change the date in Field 32 to a future date.

IV. Additional Reports:

The following reports have been produced for monitoring purposes:

FIM31434-01  MC+ for Pregnant Women Recipient Who Converted to Extended Women's Health  Services Effective (mm/dd/yy).

This monthly report will reflect only those individuals who were systematically converted from MC+ for Pregnant to Extended Women's Health Services during a given month. 

FIM31435-01  MC+ for Pregnant Women Recipients Who Lost Eligibility at End of Postpartum (Insured) Effective  (mm/dd/yy). 

This monthly report will reflect only those individuals whose MC+ for Pregnant Women eligibility was closed by the system at the end of postpartum as they are insured. 

Effective_______________ your sixty (60) day postpartum coverage under MC+ for Pregnant Women will end.

Your case is being reviewed to determine whether you qualify for continued MC+ coverage in another category of assistance.  Based on information on file, a determination of your eligibility for MC+ for Custodial Parents and Medical Assistance for Families will be completed.  If you are under the age of 19, eligibility will be determined under the MC+ for Children program.  You will be notified if your MC+ coverage changes.

Eligibility may also exist for MC+ healthcare or other medical assistance programs if any of the following apply:
 

• You have a physical or mental disability which is expected to prevent employment for at least 12 months;
• You are pregnant;
• You are blind; 
• A change in circumstances has occurred, such as a change in income; or
• As a non-custodial parent, you are current in paying child support.

Please contact me at your local Family Services Office by _____________________ if any of the above apply so we may evaluate eligibility for other MC+ healthcare or medical assistance coverage.
 

     Sincerely,
 
 

     MC+ Service Representative

Effective_______________ your MC+ for Pregnant Women sixty (60) day postpartum coverage will end.

Your case is being reviewed to determine whether you qualify for continued MC+ coverage in another category of assistance.  Your eligibility is being explored for Medical Assistance for Families based on the information on file.  You will be notified if your MC+ coverage changes.  If you are under the age of 19, eligibility will be determined under the MC+ for Children program. 

Our records reflect you currently have other health insurance coverage.  If this is incorrect, it is important you notify our office as this could affect your eligibility.  Income limits are higher for uninsured parents and children.  Also, uninsured women are eligible for MC+ coverage restricted to women's health services for up to two (2) years after postpartum coverage ends.

Eligibility may also exist for MC+ healthcare or other medical assistance programs if any of the following apply:

• You have a physical or mental disability which is expected to prevent employment for at least 12 months;
• You are pregnant;
• You are blind; 
• A change in circumstances has occurred, such as a change in income; or
• As a non-custodial parent, you are current in paying child support.

Please contact me at your local Family Services Office by _____________________ if any of the above apply so we may evaluate eligibility for other MC+ healthcare or medical assistance coverage.
 

     Sincerely,
 
 

     MC+ Service Representative

Effective_______________ your sixty (60) day MC+ for Pregnant Women postpartum healthcare coverage ended.  As an uninsured person, you do not qualify for extended women's health services. (13CSR 70-4.090)  Eligibility could not be established under Medical Assistance for Families as income exceeded the allowable limits for the number of eligible children you reported in your home.  (13CSR 40-2.120) We do not have any information that indicates eligibility for any other MC+ or medical assistance program.

You may call 1-800-TEL-LINK (1-800-835-5465) to identify where to go for family planning services and a variety of other services for families.

You have the right to appeal decisions made involving your coverage.  You can request a hearing within 90 days from the date of this notice by contacting your MC+ Service Representative.  If you request a hearing you may present your information yourself or you may be represented by your own attorney or by other persons who know your situation.  You have the right to present witnesses in your behalf and to question witnesses who appear at the request of the MC+ Service Representative.

      Sincerely,
 

      MC+ Service Representative

Effective_______________ your sixty (60) day MC+ for Pregnant Women postpartum healthcare coverage ended.  As an uninsured woman, you are eligible for women's health services for up to two years after your postpartum coverage expires.  Your eligibility for this coverage will begin effective______________ and continue through_____________ unless you become eligible for another MC+ program or obtain other health insurance coverage.

Covered services include the following:

• Approved methods of birth control
• Sexually transmitted disease testing and treatment, including pap test and pelvic exams;
• Family planning counseling/education on various methods of birth control; or
• Drugs, supplies, or devices related to women's health services described above that are prescribed by a physician or advanced practice nurse.

You may call 1-800-TEL-LINK (1-800-835-5465) to identify where to go for family planning services and a variety of other services for families.

Your eligibility for other MC+ healthcare was explored.  You did not qualify for Medical Assistance for Families or Custodial Parent healthcare coverage as income exceeded the allowable limits for the number of eligible children you reported in your home.  (Rules 13CSR 70-4.090, 13CSR 40-2.120) We do not have any information that indicates eligibility for any other MC+ or medical assistance program.

You have the right to appeal decisions made involving your coverage.  You can request a hearing within 90 days from the date of this notice by contacting your MC+ Services Representative.  If you request a hearing you may present your information yourself of you may be represented by your own attorney or by other persons who know your situation.  You have the right to present witnesses in your behalf and to question witnesses who appear at the request of the MC+ Service Representative.

      Sincerely,
 

      MC+ Service Representative
 

• Review this memorandum with all appropriate staff.

• Explore all other categories of assistance before allowing the MC+ for Pregnant Woman case to close or convert to EWHS.

• Implement these procedures upon receipt of the monthly reports.

• File copies of the letters and reports in the Forms Manual.