September 19, 2007

1. September 19, 2007

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3. 3 How to apply (continued) Presumptive Eligibility for Pregnant Women (PEPW) Complete the paper application (Health Insurance Application for Pregnant Woman, CF-ES 2700) Simplified Eligibility for Pregnant Women (SEPW) Complete the paper application (Health Insurance Application for Pregnant Woman, CF-ES 2700) Other Medicaid, including Medically Needy Complete either the electronic (WEB-APP) or paper ACCESS Florida application (AFA)

4. 4 Submit Application for�. Presumptive Eligibility for Pregnant Women (PEPW) to a Qualified Designated Provider (QDP). Simplified Eligibility for Pregnant Women (SEPW) to the DCF ACCESS office in person, by mail or by fax. Other Medicaid, including Medically Needy to the DCF ACCESS office in person, on-line, by mail or by fax.

5. 5 Qualified Designated Providers County Public Health Units (CPHU) (aka: County Health Departments) Florida Department of Health Children�s Medicaid Services (CMS) CMS Programs -- Children's Medical Services Homepage Regional Perinatal Intensive Care Centers (RPICC) (i.e., certain designated regional hospitals) CMS RPICC Family Brochure Information

6. 6 Eligibility Determination Procedure Presumptive Eligibility for Pregnant Women (PEPW) Presumptive eligibility determination by QDP using procedures outlined in CF-Operating Procedure 165-9. Application forwarded to DCF within 5 days of determination. Simplified Eligibility for Pregnant Women (SEPW) Simplified eligibility determination by DCF using abbreviated verification procedures. Other Medicaid, including Medically Needy Normal application processing by DCF.

7. 7 Required Verification Presumptive Eligibility for Pregnant Women (PEPW) Proof of pregnancy from a medical provider. Verbal Statement of Income Simplified Eligibility for Pregnant Women (SEPW) Proof of pregnancy from a medical provider. Proof of citizenship and identity for US citizens. Proof of non-citizen status for non-citizens. Proof of self-employment income and other verification as needed, such as a Social Security Number. Other Medicaid, including Medically Needy Proof of pregnancy from a medical provider. Proof of citizenship and identity for US citizens. Proof of non-citizen status for non-citizens. Proof of income and assets for all household members. Other verifications, such as a Social Security Number.

8. 8 Extent of Medicaid Coverage Presumptive Eligibility for Pregnant Women (PEPW) � Limited Coverage: Covers the pregnant woman only. Covers pregnancy related outpatient services and prescriptions only. Only one presumptive period per pregnancy allowed. Simplified Eligibility for Pregnant Women (SEPW) � Full Coverage: Covers the pregnant woman only. Covers all Medicaid services, including inpatient services and delivery. Other Medicaid, including Medically Needy � Full Coverage: Covers all Medicaid services for all eligible household members, if requested.

9. 9 Duration of Medicaid Coverage Presumptive Eligibility for Pregnant Women (PEPW) Begins the date of application and lasts until DCF makes a determination of ongoing eligibility, or 60 days (whichever is less). Simplified Eligibility for Pregnant Women (SEPW) Begins the first day of the application month and lasts through two (2) post-partum months. Up to three (3) months retroactive coverage available, if eligible and requested, provided woman was pregnant during the retroactive period. Other Medicaid, including Medically Needy Other Medicaid: Begins the first day of the application month and lasts through two (2) post-partum months. Medically Needy: Begins the date that Share of Cost is met. Up to three (3) months retroactive coverage available, if eligible and requested.

10. 10 Policy Manual References Presumptive Eligibility for Pregnant Women (PEPW) PEPW 2030.0704 Simplified Eligibility for Pregnant Women (SEPW) SEPW 0630.1500 Other Medicaid, including Medically Needy Family Related Medicaid Application for Assistance 0630.0000

11. 11 PEPW DETAILS Standard Filing Unit (SFU): Definition � those family members who are living together and whose needs and income are considered in the pregnant woman�s Medicaid eligibility budget calculation. This includes the unborn child (or children if multiple births are anticipated). Eligibility for PEPW Medicaid coverage is dependent on the pregnant woman�s Standard Filing Unit (SFU) having countable income less than or equal to 185% of the Federal Poverty Level (FPL).

12. 12 PEPW SFU EXAMPLES Mary, age 20 and unmarried, is pregnant. She lives with her parents and minor brother, age 17 (has no income). Her SFU includes: Mary Her unborn child Her parents Her brother Denise, age 22, is pregnant. She is separated from her husband. Her SFU includes: Denise Her unborn child

13. 13 PEPW SFU EXAMPLES (continued) Joan is 25, pregnant and living with Dan, the father of her unborn child. Her SFU includes: Joan Her unborn child Dan Jennifer, age 20, lives with her husband and 2 year old son. She is pregnant with twins. Her SFU includes: Jennifer Two unborn children Her husband Her son

14. 14 Processing PEPW on the FLORIDA System Both FMMIS and FLORIDA must be reviewed to determine if the pregnant woman is already receiving Medicaid. If yes, no further action is necessary. If no, complete the following steps: Have the pregnant woman complete and sign the application form (CF-ES 2700). Copy her identification, if available. Complete client registration and the pregnant woman driver (ASPW) on FLORIDA, using information from the application. If eligible, give (or mail) her temporary proof of Medicaid eligibility (AMIC). Forward the application and any documentation (i.e., proof of identity, proof of pregnancy) to the local DCF ACCESS office using local procedures. Add the case to the tracking log (CF-ES 2679).

15. 15 Manual PEPW Determination Complete the following steps: Have the pregnant woman complete and sign the application form (CF-ES 2700). Copy her identification, if available. Use information from the application to complete the PEPW manual intake form (CF-ES 2695). Health Department staff must complete the Financial Eligibility Form (DH -3130) All other QDP staff complete the Medicaid Presumptive Eligibility Worksheet (CF-ES 2680) Add the case to the tracking log (CF-ES 2679). If the pregnant woman is eligible for PEPW: Complete the Notice and Proof of Presumptive Eligibility for Medicaid form (CF-ES 2681), leaving the Medicaid ID number blank. Forward all forms and any documentation (i.e., proof of identity, proof of pregnancy) to the local DCF office within 5 calendar days. If the pregnant woman is NOT eligible for PEPW: Forward all forms and any documentation (i.e., proof of identity, proof of pregnancy) to the local DCF office within 5 calendar days.

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17. 17 PEPW Operating Procedure Click on the following hyperlink to review the PEPW Operating Procedure. DCF Operating Procedure 165-9 - Presumptive Medicaid Eligibility for Pregnant Women

18. 18 U.S. Citizenship and Identity Verification Policy for Medicaid This policy does not apply to PEPW (see slide # 7). Most individuals who indicate they are U.S. citizens on the application must provide verification of their citizenship and identity. Exceptions: Individuals who are� SSI recipients, Social Security Disability (SSDI) recipients, Children in state foster care or adoption, Medicare (any part) recipients. Medicaid cannot be authorized prior to receipt of verification. For a list of acceptable verification documents go to: http://www.dcf.state.fl.us/ess/docs/dra_verify.pdf

19. 19 SEPW Income Verification Policy Income verification is not required prior to disposition of the SEPW application, unless the income is questionable. DCF staff must� Verify income using data exchange, prior to disposition of the application, whenever possible. If the applicant�s statement of income on the application, or the data exchange information from the same income source, does not exceed 185% of the federal poverty level (FPL), the income can be considered as verified. If the income on the application is questionable or incomplete, the applicant and/or employer must be contacted by phone to obtain necessary clarifying information. Otherwise, it will be necessary to pend the application for written income verification. If income is not verified prior to approval, it must be verified following approval, using data exchange information, whenever possible. It may also be verified via mail or telephone collateral contact with the employer. NOTE: This same income verification policy is followed for the Medicaid Family Planning Waiver

20. 20 Medicaid for Pregnant Women Women closed to Pregnancy Medicaid coverage at the completion of 2 postpartum months are automatically enrolled in the Medicaid Family Planning Waiver Program for the first year of eligibility. The woman must actively apply for the second year of the program. Assigned a Medicaid eligibility category of FP Need to keep their �gold card� for FP services

21. 21 Emergency Medical Assistance for Aliens (EMA) Non-citizens who would be Medicaid eligible on all factors, except for their citizenship status, may be eligible for Medicaid to cover medical emergencies, including the birth of a child. Before Medicaid may be authorized, applicants must provide proof from a medical professional stating the medical treatment was due to an emergency condition and the dates of the emergency. Medicaid can be approved only for the period of the verified emergency. Non-citizens who are in the US for a temporary reason, such as tourists, students, or those traveling for business, are not eligible for EMA, or any other Medicaid benefits.

22. The End Questions? Call 1-866-76ACCESS (1-866-762-2237)