0105.025.15.15 MC+ for Pregnant Women (MPW)

IM-105 August 23, 2002

Provide to the claimant the following leaflets:

  1. HCY, if applicable
  2. Income Guidelines, MC-4A
  3. Important Information, MC-4
  4. Non-Emergency Medical Transportation
  5. Health Insurance Premium Payment (HIPP) Program

Complete the following forms, at a minimum:

  1. Application and Eligibility Statement, IM-1UA
  2. TPL Form (if necessary)
  3. Referral for Social Security Number SSN-1 if needed
  4. Request for Information (if needed)
  5. HIPP-1, if applicable

Explain the following eligibility requirements:

  1. Social Security Number
  2. Residence
  3. Citizenship
  4. Alien Status
  5. Need
  6. Confirmation of Pregnancy and Expected Delivery Date
  7. Prior Quarter Coverage
  8. Dual Eligibility for GR, if applicable,
  9. 60 Day Postpartum Eligibility
  10. Extended Women's Health Services