Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 28 - Division of County Operations
Rule 016.28.22-008 - Expansion of Pregnant Women Medicaid
Current through Register Vol. 49, No. 9, September, 2024
Section I
The Department of Human Services (DHS) local county offices or district Social Security offices determine beneficiary eligibility for most Medicaid beneficiaries.
District Social Security offices determine Supplemental Security Income (SSI) eligibility, which automatically confers Medicaid eligibility for SSI beneficiaries.
The infants and children in the SOBRA (Sixth Omnibus Budget Reconciliation Act of 1986) aid category receive the full range of Medicaid benefits.
Pregnant Women (PW)-eligibility ends on the last day of the month in which the 60th postpartum day occurs.
PW-Unborn Child group (covered through the State Child Health Insurance program, which is authorized by Section 4901 of the Balanced Budget Act of 1997) does not cover sterilization or any other family planning services. Therefore, providers must verify eligibility to determine if the pregnant women is PW-or PW "Unborn Child" (when providers check eligibility, the system will reflect: "PW Unborn CH-no Ster cov" for the Unborn Child group).
Aid Category 61 also includes benefits to unborn children of alien pregnant women who meet the eligibility requirements. The benefits for this eligibility category are:
Section II Nurse Practitioner
Arkansas Medicaid encourages reproductive health and family planning by covering a comprehensive range of family planning services provided by nurse practitioners and other providers. Medicaid clients' family planning services are in addition to their other medical benefits. Family planning services do not require PCP referral.
Women in Aid Category 61, Pregnant Women (PW), are eligible for all Medicaid-covered family planning services through the last day of the month in which the 60th day postpartum falls.
Aid Category 61 PW Unborn Child does not include family planning benefits.
The Arkansas Medicaid Program covers obstetrical services for Medicaid-eligible clients in full coverage aid categories with a medically verified pregnancy.
Aid category 61, PW clients are eligible for full range Medicaid coverage. Aid category 61, PW pregnant women's eligibility ends on the last day of the month in which the 60th postpartum day falls.
Section II Physician/Independent Lab/CRNA/Radiation Therapy Center
Women in Aid Category 61, Pregnant Women (PW), are eligible for all Medicaid-covered family planning services. Clients in aid category 61 Pregnant Women (PW) are eligible for family planning services through the last day of the month in which the 60th day postpartum falls.
Women in Aid Category 61 (PW) receive the full range of Medicaid benefits. Aid Category 61 also includes benefits to unborn children of alien pregnant women who meet the eligibility requirements. The benefits for this eligibility category are:
System eligibility verification will specify "PW unborn ch-no ster cov/FP."
Aid Category 61 PW Unborn Child does not include family planning benefits.
Section II ARKids First-B
Medicaid-eligible children in the SOBRA eligibility category for pregnant women, infants, and children (category 61 PW) and newborn children born to Medicaid-eligible mothers (categories 52 and 63), are known as ARKids First-A clients. Uninsured, non-Medicaid-eligible children that meet additional established eligibility requirements will have health coverage under ARKids First-B, a CHIP separate child health program. All ARKids First clients will receive a program identification card without indication of level of coverage (either ARKids First-A or ARKids First-B).
A Medicaid eligibility verification transaction response either through the provider portal via the web or through the Voice Response System (VRS) will indicate that the individual is either an ARKids First-A client or an ARKids First-B client. The response will also indicate that cost sharing may be required for ARKids First-B clients. Refer to Section I of the Arkansas Medicaid provider manual for automated eligibility verification procedures.
When a child presents as an ARKids First-A eligible client, the provider must refer to the regular Medicaid provider policy manuals. When an ARKids First-B eligible client is identified, the provider must refer to the ARKids First-B Provider Manual for determination of levels of coverage, as well as the associated Medicaid provider policy manuals for the services provided.
Section II Hospital/Critical Access Hospital (CAH)/End Stage Renal Disease (ESRD)
Women in Aid Category 61, Pregnant Women (PW), are eligible for all Medicaid-covered family planning services.
Clients in Aid Category 61, Pregnant Women (PW) are eligible for family planning services through the last day of the month in which the 60th day postpartum falls.
Aid Category 61 PW Unborn Child does not include family planning benefits.
See Sections 216.100 -216.110, 216.130-216.132, 216.500-216.515, and 216.540-216.550 for family planning services, billing, and coverage restrictions.
Section II Certified Nurse-Midwife
Women eligible in Aid Category 61, Pregnant Women (PW), are eligible for all Medicaid-covered family planning services. Clients in aid category 61 are eligible for family planning services through the last day of the month in which the 60th day postpartum falls.
Aid Category 61 also includes benefits to unborn children of alien pregnant women who meet the eligibility requirements. The benefits for this eligibility category are:
System eligibility verification will specify "PW unborn ch-no ster cov/FP."
Aid Category 61 PW Unborn Child does not include family planning benefits.
Aid Categories 62 (PW-PE), 65 (PW-NG), 66 (PW-EC) and 67 (PW-SD) only cover the pregnant woman. Aid Categories 65, 66 and 67 have lower income limits than those listed above for Aid Category 61. Only Aid Category 61 may include eligible pregnant women and/or children.
MEDICAL SERVICES POLICY MANUAL,
Retroactive eligibility for Pregnant Women (PW) is determined according to the guidelines for current PW eligibility determination. The applicant should have alleged medical expenses for the retroactive period. (Refer to the "No Look Back" policy at MS C-205 and I-610).
The begin date of the retroactive period will be entered in the system at certification (when authorized in conjunction with current PW eligibility).
For Full PW, if application for retroactive PW coverage is made after termination of the pregnancy, the retroactive period may not begin more than three (3) months prior to the date of application, and the retroactive period must end no later than the last day of the month of delivery (for example, the applicant will not be eligible for the postpartum coverage).
(Refer to MS C-205.)
Note: Retroactive coverage for Unborn Pregnant Woman will follow the rules for the type of pregnancy coverage her eligibility falls in, Full Pregnant Woman as stated above.
Procedures for authorizing retroactive eligibility only (for example, "fixed eligibility") are found in (MS A-220).
If application for retroactive PW coverage is made after termination of a pregnancy and coverage after the month of delivery is also requested, a separate applicant must be made in the appropriate category to provide coverage for the month(s) following the expiration of the PW coverage.
An individual found eligible may receive PW Medicaid coverage only during the period of pregnancy and through the end of the month in which the sixtieth (60th) day postpartum falls. Postpartum coverage will be provided to women who are Health Care certified at the time of delivery and to women who have a Health Care application pending at the time of birth and are later found eligible for PW coverage.
An individual who applies for Pregnant Woman - Full or Medically Needy Medicaid after termination of a pregnancy may be given benefits to the end of the birth month, if eligible, but may not be given postpartum coverage. A pregnant woman who applies after the birth of the child and is found eligible in the birth month for Unborn Child will be given full postpartum coverage.
If the pregnant woman has medical bills in the three (3) months prior to the date of application, retroactive eligibility will be determined. There must have been medical bills incurred to give retroactive coverage. The medical bills must be for the PW. Medical bills for other family members will not qualify the PW for retroactive PW coverage.
If a PW applicant is not income eligible in the month of application or the month in which the forty-fifth (45th) day falls but is income and otherwise eligible in one (1) of the retroactive months, the application will be approved beginning in the earliest month of retroactive eligibility. Eligibility will then continue through the end of the month in which the sixtieth (60th) day postpartum falls, if the applicant is eligible for the postpartum coverage, with disregard of any income changes which occurred after the beginning month of eligibility.
There will be "No Look Back" at later income increases throughout the pregnancy and the postpartum period, even if the applicant is not eligible in the month of application or in the month when the forty-fifth (45th) day of the application falls. Refer to MS I-610.
Each individual applying for or receiving Medicaid benefits must have a financial eligibility determination made at application and, if eligible, on an on-going annual basis or when a change affecting eligibility occurs. Financial eligibility consists of an income test and if the category requires, a resource or asset test.
Most Medicaid eligibility groups have an income limit which an individual's countable income must fall under in order to be eligible for coverage in that group. Income limits and the manner in which countable income is determined vary by eligibility groups. The groups to which an income limit does not apply, and therefore no income determination is made, are the following:
* Newborns (MS B-220);
* Former Foster Care Adults (MS B-280);
* Workers with Disabilities (MS B-330).
NOTE:For the Workers with Disabilities category, before determining eligibility, the applicant must pass a pre-test screening to ensure his/her unearned income does not exceed the SSI individual benefit plus $20. If the applicant meets this criteria, all income is disregarded in the financial eligibility determination. However, both unearned and earned income will be used to determine cost sharing. See MS A-115.
A resource limit applies to most of the eligibility groups that do not use MAGI methodologies for financial eligibility. For these groups, the value of an individual's countable resources must be determined. There is no resource limit, and therefore no resource determination is made, for the following groups:
* Those using MAGI methodologies (MS E-110);
* Newborns (MS B-220);
* Former Foster Care Adults (MS B-260);
* Workers with Disabilities (MS B-330).
Below are the income and resource limits for all Health Care groups. When the income limit is based on a percentage of the federal poverty level (FPL), the countable household income will be compared to the FPL for the applicable household size. Refer to Appendices F and S for the specific income level amounts.
|
Category |
Income Limit |
Resource Limit |
|
ARKids A |
142% of FPL * |
No Resource Test |
|
ARKids B |
211% of FPL * |
No Resource Test |
|
Newborns |
No Income Test Eligibility is based on mother's Health Care eligibility at child's birth |
No Resource Test |
|
Pregnant Women: Full Pregnant Woman Unborn Child |
209% FPL* 209% of FPL * |
No Resource Test |
|
Parent and Caretaker Relative |
1 person: $124.00 2 person: $220.00 3 person: $276.00 4 person: $334.00 5 person: $388.00 See Appendix F for household sizes over 5. |
No Resource Test |
|
Adult Expansion Group |
133% of FPL * |
No Resource Test |
|
Medically Needy: Exceptional (EC) Spend Down (SD) |
EC - may not exceed the monthly income limit SD - may exceed the quarterly income limit See MS O-710 for the monthly and quarterly income limit |
1 person: $2,000 2 person: $3,000 3 person: $3,100 |
|
TEFRA |
3 times the SSI Payment Standard Appendix S |
$2000 |
|
Autism |
3 times the SSI Payment Standard Appendix S |
$2000 |
|
Long-Term Services & Supports: Nursing Facility, DDS, ARChoices, Assisted Living, and PACE |
3 times the SSI Payment Standard Appendix S |
Individual $2000 |
|
Couple $3000 |
||
|
Medicare Savings: ARSeniors QMB SMB QI-1 QDWI |
Equal to or below 80% F PL 100% FPL Between 100% & 120% F PL 120% but less than 135% F PL 200% FPL Appendix F |
ARSeniors, QMB, SMB & QI-1: Individual $7,730 Couple $11,600 QDWI: Individual $4000 Couple $6000 |
|
Workers with Disabilities |
Unearned income may not exceed SSI individual benefit plus $20 |
No resource test |
|
PICKLE |
Under the current SSI/SPA level Appendix S |
Individual $2000 |
|
Widows & Widowers with a Disability (COBRA and OBRA '87) |
Under the current SSI/SPA level Appendix S |
Individual $2000 |
|
Widows & Widowers with a Disability and Surviving Divorced Spouses with a Disability (OBRA '90) |
Under the current SSI/SPA level Appendix S |
Individual $2000 |
|
Disabled Adult Child (DAC) |
Under the current SSI/SPA level Appendix S |
Individual $2000 |
|
*May be eligible for an additional 5% disregard, MS E-268. |
||
The Office of Child Support Enforcement (OCSE) is mandated to provide services to all Health Care recipients who have assigned their rights to medical support to the State. Each applicant or recipient who is responsible for the care of a dependent child must cooperate with OCSE in establishing legal paternity and obtaining medical support for each child who has a parent absent from the home. (See exception below.)
OCSE must provide all appropriate services to Health Care applicants and recipients without the OCSE application or fee. The OCSE agency is required to petition for medical support when health insurance is available to the absent parent at a reasonable cost. OCSE will also collect child support payments from the absent parent unless OCSE is notified by the recipient in writing that this service is not needed. Child support payments collected on behalf of Health Care recipients are received and distributed to the custodial parent through the OCSE Clearinghouse. However, no recovery cost will be collected.
When a child's parent, guardian, or caretaker relative voluntarily requests a referral to be made, or is receiving Health Care, an OCSE referral will be made at initial approval. Refer to Exception and Note below.
Act 1091 of 1995, amended by Act 1296 of 1997, requires that both parents sign an affidavit acknowledging paternity, or obtain a court order, before the father's name will be added to the birth certificate.
NOTE: If the father's name is included on the birth certificate of a child born April 10, 1995, or later, paternity has already been established. As paternity establishment is the only service the Office of Child Support Enforcement can offer to a family when both parents are in the home, there is no need to make a referral in these instances.
NOTE: For child-only cases, cooperation with OCSE is voluntary. The only time that a referral to OCSE is necessary is when a parent, guardian, or caretaker relative is eligible in another Health Care eligibility group in which cooperation with OCSE is mandatory. Cooperation with OCSE will be strictly voluntary when a:
* Parent, guardian, or caretaker relative is not receiving Health Care, but the children are receiving Health Care;
* Parent, guardian, or caretaker relative is the only one receiving Health Care and the children are not receiving Health Care; or
* Parent, guardian, or caretaker relative is receiving Health Care in an exempt category.
A parent is considered to be absent for Health Care purposes when the absence is due to divorce, separation, incarceration, institutionalization, participation in a Rehabilitation Service Program away from home, or military service. These considerations are regardless of support, maintenance, physical care, guidance, or frequency of contact.
An applicant or recipient may have good cause not to cooperate in the state's efforts to collect child or Medical support. The applicant or recipient may be excused from cooperating if they believe that cooperation would not be in the best interest of the child, and if the applicant or recipient can provide evidence to support this claim.
The following are circumstances under which DCO may determine that the applicant or recipient has good cause for refusing to cooperate:
* Cooperation is anticipated to result in serious physical or emotional harm to the child.
* Cooperation is anticipated to result in physical or emotional harm to the individual that is so serious it reduces the ability to care for the child adequately.
* The child was born as a result of forcible rape or incest.
* Court proceedings are in progress for the adoption of the child.
* The individual is working with an agency helping to decide whether or not to place the child for adoption.
A child's Health Care benefits cannot be denied or terminated due to the refusal of a parent or another legally responsible person to assign rights or cooperate with OCSE in establishing paternity or obtaining medical support. Health Care for the parent or caretaker relative will end after the appropriate notice has expired.
If a parent or another legally responsible person states that they refuse to cooperate with the OCSE referral process during any case action (such as during the initial application or case change), the sanction can be applied by the DHS Eligibility Worker.
