Family and Children's Medicaid MA-3265 MEDICAID FAMILY PLANNING WAIVER

II. POLICY FUNDAMENTALS AND ELIGIBILITY REQUIREMENTS

A. To receive FPW, the person must meet the following requirements

1. Be a citizen of the U.S. or be an alien who meets the requirements in MA-3332, US Citizenship Requirements or MA-3330 Alien Requirements. An undocumented alien is ineligible for this program.

2. Be a resident of NC as defined in MA-3335, State Residence.

3. Not be an inmate of a public institution. See MA-3360, Living Arrangements.

4. Not be in an institution for mental diseases. However, individuals under age 21 receiving inpatient psychiatric care or individuals age 21 through 55 for women and through 60 for men in the medical/surgical unit of the state mental hospitals are eligible for assistance. See MA-3360, Living Arrangements.

5. Meet income criteria according to MA-3300, Income

6. Not be receiving Medicaid for his own needs from another assistance category, county or state. The applicant/recipient must be ineligible for Medicaid benefits under any other aid/program category or have exhausted the MPW 60 day postpartum period. This includes MAABD as well as F&C aid/program categories. At the point an NCHC child ages out of NCHC or MIC, consider this person for FPW.

7. Provide verification of all health insurance coverage for himself and assign to the State all rights to third party payments from any such insurance coverage.

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8. Furnish his SSN or apply for a number if he does not already have one or furnish all SSN’s which have been used or under which benefits have been received. See MA-3355, Enumeration Procedures.

9. Must cooperate with Child Support Enforcement if he or she is a caretaker of a child receiving Medicaid or if the child is 19 or 20 years old, has an existing support order established before age 18 and is attending primary or secondary school. If the child is an SSI recipient do not make a referral to Child Support Enforcement.

10. Not be sterile. Accept the applicant/recipient’s statement.

11. Women must be age 19 through 55 years old and men must be age 19 through 60 years old.

12. Not receive Medicare.

A. FPW REQUIREMENTS

1. Income Limit

The maximum income limit to be eligible for FPW is at or below 185% of the federal poverty level.

a. The assistance unit consists of only one person.

b. The budget unit consists of applicant and his or her spouse.

c. The needs unit consists of the budget unit plus any children living in the home as instructed in MA-3305, MAF, HSF, MIC Budgeting.

d. Only spouse for spouse financial responsibility exists. Do not count parent’s income in determining eligibility for those under age 21.

2. Managed Care

FPW recipients are not required to choose a primary care physician through the Community Care of North Carolina/Carolina Access (CCNC/CA) program. Do not enter a provider code or exemption code for any applicants approved for FPW.

While Managed Care does not apply to FPW applicants/recipients (a/r), you may assist in helping them find a doctor. Provide each a/r with a primary care provider directory of local doctors accepting Medicaid in his county.

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C. Identification Card

A Medicaid identification card will be issued for recipients of FPW. The card does not indicate that coverage is limited under this program. It is up to the provider to check program limitations along with eligibility for each date of service.

D. Resources

Do not count resources in determining eligibility for FPW.

E. Transportation Services

FPW recipients are eligible for Medicaid funded transportation services for family planning services only. See MA-3550, Medicaid Transportation.

F. Application Processing Standard

The application processing standard is 45 calendar days.

G. Certification Period

The certification period is 12 months for an ongoing case. The certification period can be adjusted to match the family’s other Medicaid cases, following instructions in MA-3425, Certification and Authorization.

1. The certification period begins the first day of the month of application if the individual(s) is eligible in that month, or the first day of the month in which the applicant meets all eligibility requirements within the 45 day processing period.

2. If the individual(s) received Medicaid in another aid program/category, the FPW period begins the first day of the following month in which he did not receive Medicaid.

3. If the individual is eligible for FPW as a result of an ex parte review due to a change in situation causing ineligibility for Medicaid or Work First, continue with the remainder of the current certification period unless it has expired. See MA-3410, Terminations and Deletions.

H. Retroactive Coverage

Retroactive coverage is not allowed under the FPW program.

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I. Case Composition

The assistance unit can only be one person even when there are more in the budget/needs unit.

J. Automated Inquiry and Match Procedures

Family Planning applicants/recipients are subject to IEVS requirements and automated matches. Refer to MA-3515, Automated Inquiry and Match Procedures.

K. Child Support Referrals

See MA-3365, Child Support, to determine when to send a child support referral.

L. Appeals

Follow procedures in MA-3350, Notice and Hearing Process, for hearings and appeals.

M. Co-payments

There is no co-payment for FPW services.

N. Open and Shut Coverage is Allowed

FPW applications may be approved as open/shut if necessary. For example a woman turns age 56 in the month she applies. Complete an open/shut for the month the woman turns age 56.

O. TPR

The applicant/recipient must report Third Party coverage information.

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P. Buy-in

A person on Medicare is ineligible for this program.

Q. Covered Services

Services included as part of the family planning waiver include (Not all inclusive.):

1. Annual family planning exam that includes pap smear and breast exam for women and a testicular exam for men,

2. Counseling and contraceptive supply visits to support the effort to continue a pregnancy spacing plan,

3. Most methods of birth control,

4. Screening and treatment for STI (Sexually Transmitted Infections),

5. Screening for HIV (Human Immunodeficiency Virus),

6. Sterilizations for men and women over age 21.