The UWHS program provides women's health services for uninsured women from age 18 up to but not including age 56 who are in need of family planning services, and have family income up to and including 185% of the federal poverty level for their household size. Women who have been sterilized are not in need of family planning services and are ineligible for the UWHS program.
UWHS coverage is not time limited and is subject to the standard MO HealthNet reinvestigation and exparte processes.
When responding to inquiries and at application for the UWHS program, explain the benefits and services available. The only healthcare services covered by MO HealthNet for UWHS are family planning and family planning related services. The MO HealthNet Division provides guidance to MO HealthNet providers of services covered by the various Medicaid eligibility codes (ME) codes. Refer to the benefit matrix located under "Covered Services" on the About the MO HealthNet Division webpage for listing of covered services.
Senate Bill 577 (2007) added Section 208.659 to the Revised Statutes of Missouri authorizing a revision to 13 CSR 70-4.090, thereby establishing the Uninsured Women's Health Services program. The Centers for Medicare and Medicaid Services (CMS) approved an amendment to Missouri's Section 1115 Waiver, authorizing the revision in December 2008. The CMS approval allows the Family Support Division to begin accepting applications and determining eligibility for the Uninsured Women's Health Services (UWHS) program effectively immediately.
Through the UWHS program, Missouri provides women's health services to uninsured women who are in need of family planning services, from age 18 up to but not including age 56, with a family income less than or equal to 185% of the federal poverty level.
A woman must meet the following criteria to be eligible for Uninsured Women's Health Services:
NOTE: MO HealthNet for Families (MHF) eligibility factors for the criteria listed above apply, unless otherwise noted. MHF eligibility factors not listed above (such as Assignment of Support Rights, Cooperation in Obtaining Support, etc.) do not apply to the Uninsured Women’s Health Services program.
A woman must be age 18 and up to but not including age 56 to be eligible.
This factor of eligibility applies to the female applicant. It does not apply to other persons who may be included in the assistance group (i.e. spouse of woman, dependent children). Follow the instructions outlined in Section 0905.010.05 for this eligibility factor.
While obtaining a social security number is not a factor of eligibility for other persons in the assistance group, the social security number should be requested as it may be needed to verify income.
This eligibility factor is the same as for MHF. Refer to Section 0905.010.25.
This eligibility factor is the same as for MHF. Refer to Section 0905.010.30.
All MHF budgeting methodologies apply to UWHS except:
Definitions of income and income exclusions are the same as MHF unless otherwise stated.
A woman is eligible for UWHS healthcare coverage if the assistance group's net income does not exceed 185% of the federal poverty level (FPL) for the household size.
Some family members are mandatory for inclusion in the assistance group and some are optional. Others are mandatory for exclusion. Determine the assistance group by including mandatory members, and optional members whose inclusion does not adversely affect eligibility. Mandatory exclusions take precedence over the mandatory inclusions for assistance grouping.
Mandatory assistance group members include:
NOTE: The father of an included optional child is mandatory, regardless of spousal status.
The following persons must be excluded from the assistance group:
The woman has the option to include the following persons in the assistance group, unless they are a mandatory exclusion:
NOTE: Do not include optional assistance group members whose income causes ineligibility.
The need standard is the basis of several income tests used to determine a woman's eligibility for UWHS. The need standard is allowed according to the number of persons in the assistance group.
The full need standard and net income limit for UWHS is 185% of the federal poverty level (FPL), and the gross income limit is 185% of the full need standard (185% of 185%).
FAMIS determines need and applies the correct income tests based upon information entered regarding the assistance group including assistance group members, income, and expenses.
FAMIS compares income (minus overhead expenses, standard work exemption and childcare up to maximum allowed) to the 185 % FPL at application or when adding a person.
If applicable, FAMIS allows the UWHS standards for work expense and childcare, overhead expenses, and income exclusions.
Net income must not exceed 185% FPL standard for the size of the assistance group.
Net income is determined by subtracting from countable income (gross minus overhead expense) any of the following that apply:
Refer to section 0905.012.70 for more information on earned income disregards.
A woman is ineligible for UWHS when she has available resources with a value of $250,000 or more. Available resources (defined in Temporary Assistance manual, Sections 0205.005.05 through 0205.005.35) include any combination of the following:
This resource is defined in the Temporary Assistance manual, Sections 0205.005.05 through 0205.005.20.10.
This resource is defined in the Temporary Assistance manual, Sections 0205.005.25 through 0205.005.25.15.
This resource is defined in the Temporary Assistance manual, Sections 0205.005.30 through 0205.005.30.45.
This resource is defined in the Temporary Assistance manual, Section 0205.005.35.
To be eligible for UWHS, a woman must be uninsured. Uninsured women are defined as women age eighteen (18) up to fifty-six (56) years of age that do not have health insurance that covers family planning services. Refer to Section 0920.020.05.10 for definition of health insurance. A woman covered by health insurance that covers family planning services at the time UWHS eligibility is determined is ineligible, unless the insurance enrollment is already paid for by HIPP. There is no penalty for dropping insurance.
NOTE: Persons receiving Medicare are considered insured.
A woman that is insured simply because the Health Insurance Premium Payment (HIPP) program is paying the premium will be treated as though she is uninsured.
This definition is the same as for MO HealthNet for Kids. Refer to Section 0920.020.05.10.
In addition to being uninsured, the woman cannot have access to employer-sponsored health insurance (either through her employer or her spouse's) that covers family planning services. If the woman declares the available insurance does not cover family planning services, this must be verified by a copy of the insurance plan benefits or other valid plan documents. Access to insurance available through employment includes group memberships or private company insurance enrollment options offered by the employer. Examples of group memberships that could offer health insurance are a union, professional organization, or trade association.
If the woman or her spouse fails to purchase the health insurance, she is ineligible as long as it is available. It is considered available even though there is a limited open enrollment period for which they need to wait.
A woman is ineligible for UWHS if she qualifies for any other MO HealthNet program. Explore eligibility for any Family Healthcare program (MO HealthNet for Families, MO HealthNet for Kids, and MO HealthNet for Pregnant Women) prior to exploring eligibility for UWHS. If the participant has an active MO HealthNet for Families (MHF) or MO HealthNet for Kids (MHK) case, explore eligibility for MO HealthNet for Families prior to exploring eligibility for UWHS by completing an add-a-person application. If ineligible for MO HealthNet for Families or any other full coverage program, explore eligibility for UWHS by registering a UWHS application and approve for UWHS if eligible on all UWHS eligibility factors. FAMIS automatically registers a UWHS application if found ineligible for any MO HealthNet program in the FAMIS system. If the woman applies using the application for Family Healthcare programs, assume she is ineligible for MO HealthNet for the Aged, Blind, and Disabled (MHABD) unless she either indicates that she is disabled or receives Social Security disability or SSI benefits.
Examples:
Ms. Johnson meets all eligibility requirements for UWHS, but is receiving Extended Women's Health Services (EWHS). Ms. Johnson is not eligible for UWHS as she is currently receiving MO HealthNet benefits under another program. NOTE: Ms. Johnson should be reviewed for UWHS eligibility prior to closing EWHS. FAMIS registers a UWHS application in the eleventh month of EWHS coverage to explore eligibility for UWHS.
Ms. Smitt receives Social Security Disability of $650.00 per month, has resources under $1,000 and does not receive Medicare. She meets all other eligibility requirements for UWHS, but as she is disabled, she qualifies for MO HealthNet for the Aged, Blind and Disabled (MHABD) based on disability. Ms. Smitt is not eligible for UWHS as she qualifies for MHABD.
Ms. Warren receives Social Security Disability of $1,000 per month, has resources under $1,000 and does not receive Medicare. She meets all other eligibility requirements for UWHS, but as she is disabled, she qualifies for MO HealthNet for the Aged, Blind and Disabled (MHABD) based on disability. Ms. Warren is not eligible for UWHS as she qualifies for MHABD on a spenddown basis. If Ms. Warren fails to purchase the spenddown coverage, she is ineligible as long as it is available. It is considered available even though she may not choose to pay her premium.
Ms. Harmony is included on her children's MO HealthNet for Kids case. Ms. Harmony submits a MO HealthNet for Kids, Pregnant Women, and Parents application on 1-2-09. Ms. Harmony is not pregnant, disabled, or blind. The eligibility specialist registers an add-a-person application for Family Healthcare (FAM in FAMIS) and an application for UWHS. If Ms. Harmony is determined ineligible for MO HealthNet for Families, eligibility for UWHS must be explored.
Women in the Uninsured Women's Health Services program in need of family planning services are eligible for the same services as women in the Extended Women's Health Services (EWHS) program. These services are:
NOTE: Only women who are in need of family planning services can receive coverage for these services. Women who are sterilized are not eligible for UWHS.
There is no cost sharing for UWHS coverage. Services are provided through fee-for-service through approved MO HealthNet providers in all areas of the state. UWHS coverage begins the first day of the month of application provided all eligibility factors are met. UWHS does not include prior quarter coverage.
UWHS coverage is date-specific for participants at the time of closing.
Process UWHS applications without undue delay unless unusual or extreme circumstances exist. Complete the eligibility determination to ensure an applicant is mailed her notice of approval or denial within a period not to exceed 30 days.
Complete a review of UWHS eligibility every 12 months. This requirement is the same as for MHF. Refer to Section 0905.025.01.
A UWHS reinvestigation can be completed using information from an application or recertification from another program. For example, a review is completed by a Food Stamp application initial approval or recertification when all members of the UWHS Eligibility Unit are in the Food Stamp Eligibility Unit or by a Temporary Assistance application approval when all members of the UWHS Eligibility Unit are in the Temporary Assistance Eligibility Unit. When a reinvestigation of this type occurs, completion of the reinvestigation form is not required.
When a UWHS review form (FA402) is received within the same month that the case closed due to failure to complete and return a review form, take appropriate action to cancel close the case and process the review using current procedures. Refer to FAMIS User Guide, "Completing a Temporary Assistance/Medical Assistance Reinvestigation in FAMIS" for instructions on how to complete a review in FAMIS.
NOTE: Failure to enter a review in FAMIS when the case was cancel closed during the same month the reinvestigation is due will cause FAMIS to begin the adverse action process again for failure to complete and return the reinvestigation form and results in a delinquent reinvestigation. Therefore, the eligibility specialist must enter the reinvestigation during the same month the reinvestigation is due to avoid the case closing again and to avoid a delinquent reinvestigation.
EXAMPLE: Ms. Grey's review is due in February. Ms. Grey failed to complete and return her review form by the due date, and the case closed for failure to complete the reinvestigation. On February 20, Ms. Grey provides her completed review form. The eligibility specialist's supervisor cancel closes the case. The same day the eligibility specialist completes the review in FAMIS following current procedures.
Prior to discontinuing a participant's coverage under UWHS, review the participant's possible eligibility under all MO HealthNet programs. Follow steps for an exparte review in MO HealthNet for Families manual Sections 0905.025.16.05 - 0905.025.16.20.
Example:
Ms. Elrod reports that she is now insured and pregnant. Explore eligibility under MO HealthNet for Pregnant Women (MPW) prior to closing UWHS.
When closing an age-eligible woman in any MHF/MHK/MHABD program, include reviewing eligibility for UWHS in the exparte process if the participant is no longer eligible for any other MO HealthNet program. When a participant is determined ineligible for any Mo HealthNet Program in FAMIS and the participant is female and between the ages of 18-55, FAMIS will automatically register an Uninsured Women's Health Services (UWHS) application. FAMIS does not register a UWHS application if the Mo HealthNet program that is being closed is in the Legacy system.
NOTE: A woman eligible for EWHS after the 60-day postpartum eligibility for MO HealthNet for Pregnant Women ends is to remain on EWHS as long as she remains eligible. FAMIS explores eligibility for UWHS prior to EWHS ending by registering a UWHS application in the participant's eleventh month of EWHS coverage. If all information needed to determine eligibility for UWHS is in FAMIS, FAMIS approves or rejects the participant for UWHS and sends the participant an Action (FA-450) notice informing them of the decision on the UWHS application. If additional information is needed to determine eligibility for UWHS the eligibility specialist must complete an eligibility determination and FAMIS sends a Request for Information (FA-325) notice overnight requesting any additional information needed to determine eligibility.
Automatic Registration of a UWHS Application When a Participant is No Longer Eligible for another MO HealthNet Program in FAMIS
When a participant loses eligibility for any MO HealthNet program an ex-parte review is completed. Part of the ex-parte process is exploring eligibility for the UWHS program.
For MO HealthNet programs in FAMIS that receive a Pre-Closing (FA-411) notice prior to benefits being discontinued, such as MO HealthNet for Families and MO HealthNet for Kids programs, FAMIS registers a UWHS application when a Pre-Closing (FA-411) notice is sent. If eligibility can be determined based on information currently in FAMIS, FAMIS approves the UWHS application and completes action to discontinue MHF or MHK coverage. If approved for UWHS, the participant(s) receives an Action (FA-450) notice. The notice provides information on the participant's approval for UWHS and coverage for this program. If the participant's Pre-Closing (PRCL) or Adverse Action Close (AACL) is voided after a UWHS application is automatically registered, the system rejects the pending UWHS application. If the system initiates another PRCL, the system will automatically register another UWHS application.
For EWHS and TMH participants who do not receive a Pre-Closing (FA-411) notice FAMIS registers a UWHS application when the participant is in their eleventh month of coverage. If the TMH coverage is ending for not returning the quarterly report form, the system will automatically register a UWHS application the month that precedes the date TMH is scheduled to close.
Example: The Smith family consists of mom, dad, son, and daughter. The household applies 9/1/09 and is eligible for MO HealthNet for Families (MHF) beginning 9/1/09. They were not eligible for prior quarter coverage. On 9/05/09, Mr. Smith begins employment and provides verification of income to the eligibility specialist. Mr. Smith's income results in ineligibility for MHF beginning 10/1/09. The FAMIS system sends a Pre-closing (FA-411) notice and registers a UWHS application on 9/5/09 for Ms. Smith. All verification needed to determine eligibility for UWHS for Ms. Smith is in FAMIS. Ms. Smith is determined eligible for UWHS. FAMIS approves Ms. Smith's UWHS application, sends an Action (FA-450) notice, and completes action to discontinue MHF coverage.
Example: Mr. and Mrs. Jones and their two children are receiving Transitional MO HealthNet (TMH). Their Transitional MO HealthNet coverage is ending 11-30-2009. In October FAMIS registers a UWHS application for Mrs. Jones. All information necessary to determine eligibility for UWHS is in FAMIS. Mrs. Jones is determined eligible for UWHS. FAMIS approves Mrs. Jones for UWHS coverage and sends her an Action (FA-450) notice.
The participant's available resources are an eligibility requirement for the UWHS program. Available resource information for UWHS is recorded on the Net Worth (FMh2 or NETWORTH) screen in FAMIS. If available resource information is needed for approval of the UWHS application, the system creates an Insufficient System Data (ISD). The eligibility specialist must complete an eligibility determination (EDRES) to create an outstanding verification for available resources. FAMIS sends a Request for Information (FA-325) notice overnight to request available resource information. If verification is provided the eligibility specialist enters this information on the Net Worth (FMh2 or NETWORTH) screen and FAMIS approves or rejects the UWHS application based upon the information entered and completes action to discontinue coverage for the other MO HealthNet program. If verification is not provided by the UWHS application due date, the system rejects the UWHS application and sends the participant an Action (FA-450) notice. Action to discontinue other MO HealthNet coverage is completed following the UWHS rejection.
Example: Ms. McGee is receiving Extended Women's Healthcare Services (EWHS). Ms. McGee is losing EWHS coverage as her 12 month eligibility period ends in October. FAMIS registers a UWHS application in September, Ms. McGee's eleventh month of EWHS coverage. No information regarding available resources is recorded on the Net Worth (FMh2 or NETWORTH) screen in FAMIS. FAMIS creates an Insufficient System Data (ISD). The eligibility specialist completes an eligibility determination (EDRES) to create an outstanding verification for available resources and FAMIS sends Ms. McGee a Request for Information (FA-325) notice for available resource information. Ms. McGee provides the requested information and the eligibility specialist enters the information on the Net Worth (FMh2 or NETWORTH) screen in FAMIS. Ms. McGee meets all eligibility requirements for UWHS. The eligibility specialist approves her UWHS application. FAMIS sends an Action (FA-450) notice to inform Ms. McGee of her approval and coverage for UWHS and completes action to discontinue EWHS coverage.
Exploring Eligibility for UWHS When a Participant Is No Longer Eligible for a MO HealthNet Program in Legacy
FAMIS does not register a UWHS application if the MO HealthNet program that is closed or rejected in the Legacy system. For example, if a participant's MO HealthNet for the Aged, Blind, and Disabled (MHABD) case is closing, FAMIS does not automatically register a UWHS application. However, it is required that the UWHS program be explored during the ex-parte process for the programs administered in the Legacy system. Continue to explore UWHS eligibility for any MO HealthNet programs in the Legacy system using current procedures.