Transcript Leadership Briefing Outline

Texas Medicaid Women’s
Health Program
Provider Training and Information
December 2010
WHP Provider Training
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Introduction
Provider Base
Provider Certification
Program Eligibility
Application
Benefits
Referrals
Resources
Program Updates
Page 2
Introduction
• What is the Women’s Health Program?
 The Women’s Health Program (WHP) provides low-income
women with free family planning exams, related health screenings,
and birth control through Texas Medicaid.
 In 2005, the 79th Legislature passed S.B. 747, which established
WHP.
 The program became effective January 1, 2007, after a Section
1115 Medicaid Research and Demonstration Waiver was approved
by the Centers for Medicare and Medicaid Services (CMS).
 The federal government’s purpose for allowing family planning
waivers is to limit federal expenditures for Medicaid-paid births.
Page 3
Introduction
 Benefits of the program include an annual family planning exam
and choice of contraception for 12 continuous months.
 Applications are available to women at provider offices, local state
eligibility offices, participating Women, Infant, and Children
program (WIC) offices, through community-based organizations,
and online.
 There is no cost-sharing, premiums, or co-pays for services
provided by WHP.
 At the end of the first year of the demonstration, there were 84,102
women enrolled in the program.
Page 4
Provider Base
• The majority of WHP providers are currently
Department of State Health Services (DSHS) Family
Planning contractors.
• Private providers who accept traditional Medicaid
clients may see WHP clients.
• To serve WHP clients, providers need to enroll as Texas
Medicaid providers through the Texas Medicaid and
Healthcare Partnership (TMHP).
Page 5
Provider Certification
• Section 32.0248, Human Resources Code, prohibits
payment of WHP funds to a provider that performs
elective abortions.
• A provider that performs elective abortions (through
either surgical or medical methods) for any patient is
ineligible to serve WHP clients and cannot be
reimbursed for those services.
• The Health and Human Services Commission
(HHSC) may recoup WHP funds that it determines
were paid to providers that have performed elective
abortions.
Page 6
Provider Certification
• WHP providers must disclose annually to
TMHP in writing whether or not they have
performed elective abortions within the past
calendar year.
• WHP providers must complete the WHP
Provider Certification form and submit it with
an original handwritten signature.
Page 7
Eligibility Criteria
• WHP is for women who meet the following qualifications:
 Ages 18 to 44. Women can apply the month of their 18th birthday
through the month of their 45th birthday.
 U.S. citizens and qualified immigrants.
 Reside in Texas.
 Do not currently receive full Medicaid benefits, including Medicaid
for pregnant women, CHIP, or Medicare Part A or B.
 Have a countable household income at or below 185 percent FPL.
 Are not pregnant.
 Are not sterile, infertile, or unable to get pregnant due to medical
reasons.
 Do not have private health insurance that covers family planning
services, unless filing a claim on the health insurance would cause
physical, emotional, or other harm from a spouse, parent, or other
person.
Page 8
Eligibility
• For the purposes of the WHP application, a client’s
private health insurance is considered to cover family
planning if it provides the following:
 Family planning related physician office visits and
procedures.
 Contraceptive drugs and devices.
• To make this determination, consideration should be
given to whether or not the health insurance provides
coverage; not to other issues such as high deductibles
or dollar limits on drug coverage.
Page 9
Income Eligibility
• Adjunctive Eligibility:
 A woman is adjunctively income-eligible for WHP if she or
a member of her family currently participates in:
• Temporary Assistance for Needy Families (TANF) cash
assistance.
• Food Stamps.
• The Supplemental Nutrition Program for Women,
Infants, and Children (WIC).
• Children’s Medicaid.
 Proof of current participation in any of these programs
means a woman has already proven her income eligibility
for WHP to the State. However, she must still provide
verification of citizenship and identity.
Page 10
Income Eligibility
• To determine income eligibility for women who do not
have proof of adjunctive eligibility, you must
determine:
 Household composition/size.
 Monthly income and expenses.
Page 11
Income Eligibility
•
Household Composition
 The budget group consists of the applicant, her spouse, and all mutual and nonmutual children.
 If an unmarried woman lives with a partner, ONLY count his income and his
children as part of the budget group IF the woman and her partner have mutual
children together.
 Treat applicants who are 18 years of age as adults.
 No children aged 18 and older or other adults living in the household should be
counted as part of the budget group.
•
Examples:
 Mrs. Thomason is married and has 3 children. The budget group consists of
herself, her spouse, and any mutual and non-mutual children.
 Ms. Thomason lives with the father of her children and is not married. The budget
group consists of herself, the father of the children, and their children.
 Ms. Small lives with her parents and does not have children. The budget group
consists of only Ms. Small.
 Ms. Small and her 2 children live with her parents. The budget group consists of
Ms. Small and her children.
•
There are no verification requirements for household determination.
Page 12
Income Eligibility
•
Converting income to Monthly Income:
 Use the income spreadsheet available at www.hhsc.state.tx.us/womenshealth.htm to
help determine monthly household countable income.
 You will frequently be required to convert income to a monthly amount. To
convert income, multiply:
• Weekly amounts by 4.33.
• Bi-weekly amounts by 2.17.
• Semi-monthly amounts by 2.
•
Example: Ms. Johnson works for T-Mart and is paid weekly. She provides two
check stubs: 11-01-06 for $235 and 11-22-06 for $225. Both are representative.
Use the most recent check stub and multiple by 4.33. $225 x 4.33 = $974.25. This is
her monthly gross income.
•
Note: When income is new or terminated, and only a partial month's income is in
the start or terminate month, do not convert the income. Use actual (income
already received), unconverted income.
Page 13
Income Eligibility
•
•
To determine if a woman is income eligible,
check the allowable converted income for the
appropriate family size, using the 185% FPIL
income chart located at:
http://www.dads.state.tx.us/handbooks/Texa
sWorks/C/100/100.htm#secC-131
This information typically changes annually
in April. Please be sure to use the most
updated chart.
Page 14
Application
• Women can fill out an application at the point of service delivery
(participating doctor’s office), and receive services the same day.
• Providers can accept a woman’s statement on her address and
Texas residency status, her household composition information,
and her Social Security number. No further documentation is
required for these eligibility points.
• Providers will need to collect, document, and fax to state eligibility
workers proof of:
 Household Income (if applicable).
 Household Expenses (if applicable).
 Citizenship.
 Identity.
 Adjunctive eligibility (if applicable).
Page 15
Application
• Women with pregnant women's Medicaid can have
coverage for up to two months postpartum.
 WHP applications can be submitted for women with Medicaid
coverage during their final month of Medicaid coverage or after
their coverage expires. Submissions prior to the final month of
Medicaid coverage will be denied.
 If the WHP application is submitted during their final month of
Medicaid coverage, and HHSC determines the woman is eligible
for WHP, her WHP coverage will begin the first day of the month
following the termination of her Medicaid coverage.
• Please review completed applications with clients
before faxing them. If an application is submitted with
incorrect client information, the client will have to call
HHSC to make corrections (1-866-993-9972).
Page 16
Income Verification
• Proof of Household Income:
 One check stub issued in the last 60 days.
 Letter from employer.
 Proof of self-employment income, unemployment benefits,
child support, SSI, other contributions, etc.
OR
• Proof of Adjunctive Eligibility:
 Current Children’s Medicaid ID letter.
 Active WIC Verification of Certification.
 Active WIC Voucher.
 Active WIC/EBT Shopping List.
Page 17
Expense Verification
• Proof of Household Expenses:
 Dependent care
• Statement or a current bill from provider, current receipts, or
income tax return.
 Child Support Paid by Household
• Attorney General collection and distribution records, or
County Clerk records.
• Cancelled checks or wage withholding statements.
• Withholding statements from unemployment compensation.
• Statement from the custodial parent regarding direct payments
or third party payments paid on their behalf.
Page 18
Citizenship and
Identity Verification
•
Combined Proof of Citizenship and Identity:
 U.S. Passport
 Certificate of Naturalization (Form N-550 or N-570)
 Certification of U.S. Citizenship (Form N-560 or N-561).
•
Proof of Citizenship:
 A U.S. birth certificate
• For an out-of-state birth, women may obtain a birth certificate through
http://www.cdc.gov/nchs/howto/w2w/w2welcom.htm
• For women born in Texas without a birth certificate, HHSC eligibility workers
can attempt to verify citizenship. The application must include the woman’s
first and last name, her maiden name, and her mother’s maiden name.
 A U.S. Citizen Identification card (Form I-179 or I-197)
•
Proof of Identity:
 Current driver’s license (from Texas or another state).
 Texas ID card issued by DPS.
 Work or school ID card with photo.
•
There are more documents that are acceptable as proof of citizenship and identity. For
more information, see www.hhs.state.tx.us/medicaid/flyer.pdf or the screening tool at
www.hhsc.state.tx.us/womenshealth.htm. Page 19
Application
(May 2007 updates highlighted)
Form H1867
April 2007
Women’s Health Program Medicaid Application
The Women’s Health Program provides an annual exam, health screenings and contraceptives for 12 months.
Please complete the following information for the WOMAN who is applying for benefits.
Name (Last, First, MI)
Applicant’s Maiden Name
Date of Birth (mm/dd/yyyy)
Applicant’s Mother’s Maiden Name
Social Security Number
Home Address – Street
Agency Use Only
Date Received
City
ZIP Code
County
, Texas
Complete if different from your home address or if you have a preferred address for receiving letters with confidential information:
Mailing Address – Street
City
Please provide a telephone number where you can discuss
confidential information.
State
Driver’s License or
ID Number
ZIP Code
In which county and state were you born?
County
Ethnicity (optional)
Hispanic/Latino
Area Code and Telephone Number
Non-Hispanic
Race (optional)
American Indian/Alaska Native
Black/African American
White
Asian
Native Hawaiian/Pacific Islander
Unknown
Are you a U.S. citizen? ......................................................
Yes
No (If yes, provide proof)
Are you pregnant? ............................
Are you a legal immigrant? .................................................
Yes
No (If yes, provide proof)
Are you sterile, infertile or unable to get pregnant due
Does anyone in your household currently receive WIC? .....
Yes
No (If yes, provide proof)
Yes
No
to medical reasons? ..........................
Yes
No
Do you have health insurance that covers family planning services? ..............................................................................................................
Yes
No
 If yes, will filing a claim on your health insurance cause physical, emotional or other harm from your spouse, parents or other person? ...
o If yes, explain your situation below. If needed, attach additional pages and include your name and Social Security number.
Yes
No
Do you have CHIP or Medicare Part A or B? ..................................................................................................................................................
Yes
No
Page 20
Application
(May 2007 updates highlighted)
Complete the information below for all other members of your household. DO NOT re-enter the woman’s information listed above. Attach additional pages if
you have more than four additional people living in your home. (*See page 2 for more information.)
Name (Last, First, MI)
Date of Birth
Social Security Number*
Sex*
Race*
Relation to Applicant
(mm/dd/yyyy)
List all of your household’s income here. Be sure to include money you receive from training or work; cash, gifts, loans or contributions from parents, relatives
or others; child support; and unemployment or government checks. Please provide proof of money received by each person.
Name of Person Receiving
the Money or Income
Name of Employer, Person or Agency
that Provides the Money or Income
How often is the money or income received?
(weekly, every other week, twice per month, monthly)
Amount
Received
List all of your household’s expenses for childcare, dependent care for disabled adults, alimony, court-ordered child support or the cost of transportation to
and from day care. Please provide proof of the money you pay for these expenses to receive this deduction.
How much do you pay? How often do you pay? (weekly, every other
week, twice per month, monthly)
Name, address and telephone number of person you pay
Information you provide in connection with this application is subject to verification by the Texas Health and Human Services Commission (HHSC) and other
state and federal agencies. Your signature indicates that you agree that information provided in this application may be used to determine eligibility for
yourself for the Women’s Health Program administered by HHSC.
“I certify under penalty of perjury that the information I have provided on this application is true and complete to the best of my knowledge. If it is not, I may be
subject to criminal prosecution. I understand that this is not an application for full Medicaid coverage. However, I understand that I may qualify for other
Medicaid services and I can apply at any time.”
Signature — Applicant
Signature — Witness
(Required if applicant signed with an “X”)
Date Signed
Page 21
Date Signed
Sterile and Infertile Applicants
• Applicants must answer the question:
 Are you sterile, infertile, or unable to get pregnant?
• If a client has been sterilized, she is not eligible for WHP.
 However, if a woman has received a sterilization procedure (such
as Essure), but has not had the sterilization confirmed, the woman
may still qualify for WHP. WHP covers the confirmation of a
sterilization procedure. No other WHP services are covered for
women that have received a sterilization procedure.
• Women may become sterilized through WHP and continue
receiving WHP benefits for the duration of their 12-month
coverage period, but may not renew coverage.
Page 22
Effective Date
•
WHP Effective date: A woman’s enrollment in WHP will be effective from the first
day of the month the state receives an application for the program. Eligibility
cannot precede the effective date of the program.
 Example: A woman applies for WHP on January 20th. When certified, her
enrollment will be effective from January 1st.
 It is important that providers fax in applications on the date of service to ensure that
the effective date captures the date of the visit.
• For example, if a woman has an appointment on November 30, and the
application is not faxed in until December 3, she will only be eligible from
December 1, and her visit will not be captured.
 If there is missing information and the application is pending until receipt of that
information, the effective date of enrollment remains the same if the missing
information is provided within 30 days from the file date.
 If there is missing information and the woman does NOT provide the missing
information within 30 days, she will be denied.
Page 23
Benefits
• WHP provides limited family planning benefits. It is
not the full Medicaid package.
• Specific benefits of WHP include:
 Family planning exam and Pap smear.
 Follow-up exams related to method of contraception.
 Screening for diabetes, sexually transmitted diseases, high
blood pressure, and breast and cervical cancers.
 Assessment of health risk factors—i.e., smoking, obesity,
exercise, etc.—as they relate to choice of contraception.
 Family planning counseling and education, including the
health benefits of abstinence.
 Birth control, except emergency contraception.
Page 24
Benefits
• A list of approved procedure codes can be found at the end
of this presentation and at:
http://www.hhsc.state.tx.us/WomensHealth/Documents/Prov
iderDocuments/WHPProcedureCodes.pdf
• The procedure codes must be billed with the most
appropriate family planning diagnosis codes.
• Billing guidelines can be found in Volume 2: Gynecological
and Reproductive Health, Obstetrics, and Family Planning
Services Handbook of the 2010 Texas Medicaid Provider
Procedures Manual.
Page 25
Referrals
• Treatment for conditions identified in the course of a
family planning visit are not reimbursed by WHP.
 Referrals for primary care are required when medically necessary.
 If you identify a health problem such as diabetes, high blood
pressure, a pap test abnormality, or a sexually transmitted
infection, you are required to refer your WHP patient to another
doctor or clinic that can treat them. It is recommended that you
utilize the established indigent care network in your area.
• Limitations:
 Referrals are limited to providers who do not perform or promote
elective abortion or contract.
Page 26
Resources
www.hhsc.state.tx.us/womenshealth.htm has:
 Program announcements.
 Training materials.
 Outreach materials.
 Applications.
 Application bulk ordering information.
 Information on eligibility and benefits.
 Lists of procedure codes and allowable prescription drugs.
 And much more.
Page 27
Resources
• Billing information and client eligibility verification
information:
 www.tmhp.com
 1-800-925-9126
• General program information for clients and
application status for clients and providers:
 1-866-993-9972
Page 28
WHP Diagnosis Codes
Page 29
WHP Procedure Codes*
Page 30