MO HealthNet for Pregnant Women (MPW) provides benefits, including sixty (60)-day postpartum benefits, for pregnant women with family income equal to or less than 196% of the federal poverty level (FPL) for the household size. Once eligible, the benefit continues through the postpartum period despite subsequent increases in income.
Federal regulation 42 CFR 435.223 along with Senate Bill 588 from the Missouri 80th General Assembly allows Title XIX benefits to pregnant women who would be eligible for AFDC cash benefits as if in fact the child had already been born. This program became effective in Missouri August 13, 1980.
The Consolidated Omnibus Budget Reconciliation Act (COBRA) P.L. No. 99-272 provides for Title XIX eligibility for pregnant women who would be eligible for AFDC based on the income and resource requirements and for 60-day postpartum Title XIX coverage for all pregnant women who received benefits under the MO HealthNet for Pregnant Women program (MPW). Deprived of Parental Support was removed as an eligibility factor for the MO HealthNet for Pregnant Women program. House Bill No. 518 enacted by the 84th General Assembly mandates these changes in Section 208.151 RSMo. An emergency clause made this part of the law effective upon passage and approval. House Bill No. 518 was signed into law July 7, 1987.
Section 208.151.1 (12) RSMo beginning January 1, 1988, provides restricted MO HealthNet benefits, including 60-day postpartum benefits, for pregnant women who have family income less than 100% of the federal poverty level.
Senate Bill No. 765 enacted by the 85th General Assembly mandates changes in Section 208.151 RSMo. Beginning July 1, 1990, Missouri provides MO HealthNet benefits, including 60-day postpartum benefits for pregnant women who have family income less than 133% of the federal poverty level, and provides continuous eligibility for pregnant women determined eligible under the MO HealthNet for Pregnant Women program when subsequent changes in income cause the claimant to become ineligible. The bill also eliminates resources as an eligibility factor.
HB 564 enacted changes effective January 1, 1994, providing Title XIX coverage to pregnant women with family income less than 185% of the federal poverty level.
Effective February 1, 1999 Missouri began providing two years of coverage for women's health services to uninsured women losing MO HealthNet for Pregnant Women (MPW) eligibility 60 days after their pregnancy ends. To be eligible for the extended women's health services (EWHS), MPW eligibility must have ended on or after January 31, 1999. A Medicaid waiver under Section 1115 of the Social Security Act authorizes this coverage.
Effective July 1, 2002 Missouri House Bill 1111 reduced the coverage for women's health services to12 months.
Effective January 1, 2014, the Patient Protection and Affordable Care Act (PPACA) of 2010 requires Family MO HealthNet programs to use Modified Adjusted Gross Income (MAGI) methodology. To reflect the PPACA requirement to remove income disregards from all Family MO HealthNet programs, the Federal Poverty Level (FPL) increased for MPW from 185% to 196%.
Women determined eligible for MO HealthNet for Pregnant Women benefits continue to be eligible despite changes in income which may cause household income to exceed the maximum. The continuous benefit ends the last day of the month in which the 60-day postpartum is completed.
All eligibility requirements in section 1805.000.00 Eligibility and Verification must be met in addition to the following:
NOTE: If a pregnant woman is rejected for MPW due to excess income or citizenship, eligibility for 1855.000.00 Show-Me Healthy Babies should be explored.
NOTE: If a pregnant woman is provided with reasonable opportunity for verification of citizenship or qualified immigrant status and fails to provide the required proof within the reasonable opportunity period, her case must be closed for "failure to cooperate." An ex parte should not be completed and coverage for Show Me Healthy Babies should not be given automatically. She must reapply for benefits. She cannot receive more than one reasonable opportunity period.
NOTE: When the pregnant woman is not the HOH and the case closes due to HOH removal (death, move out, etc.), enter a new application with the pregnant woman as HOH and use information available. Do not request any verification.
The participant must be a pregnant woman. The pregnancy is verified upon the participant's (or her representative's) attestation that she is pregnant, the estimated due date, and the number of unborn children. The Family Support Division (FSD) may request more verification if information is not reasonably compatible with the participant's attestation.
Modified Adjusted Gross Income (MAGI) methodologies apply to MPW with the addition of including all unborn children in the household size.
EXAMPLE: Jane Doe is not married to John Smith and they do not file taxes together. They are expecting triplets. Jane's household size would be four (4), including Jane and her three unborn children. John is not included because they are not married and do not file taxes jointly.
Refer to the following for additional information:
A pregnant woman is eligible for MPW benefits if the MAGI does not exceed 201% (196% plus 5% disregard) of the federal poverty level (FPL) for the household size (including the unborn child(ren)).
When a participant requests prior quarter (PQ) coverage for MPW, she must meet all eligibility factors including pregnancy. Eligibility is determined for each month separately; coverage begins on the first day of the month in which she became eligible. Once eligible, the coverage may continue through the postpartum period despite any increases in income.
The begin date for prior quarter coverage can be no earlier than the first day of the third month prior to the month of application.
NOTE: The participant statement should indicate the estimated due date to determine if she will be eligible for the entire prior quarter. If time period requested exceeds 40 weeks, this information is questionable and verification should be requested.
EXAMPLE: Ms. T applies December 10th; prior quarter coverage can be explored starting with September 1st. Ms. T attests that her due date is in July. It is appropriate to request further verification to determine what months of prior quarter can be explored.
Determine income for prior quarter months using the same methodology as the month of application. These guidelines are in manual section 1805.030.00 Modified Adjusted Gross Income (MAGI) Methodology.
When completing income budget(s) for prior quarter months, use reasonable compatibility (RC) to confirm the self-attestation of income in each month. Please refer to manual section 1805.030.15 Reasonable Compatibility for information on RC.
When the participant requests coverage for all three prior quarter months
If the participant requests coverage for all three prior quarter months and income for the first month of the prior quarter does not exceed the MPW income maximum the woman is eligible for all months of PQ if all other eligibility factors are met.
EXAMPLE: Ms. G applies/requests coverage for the current month and all three PQ months on September 15th; prior quarter coverage can be explored starting with June 1st. Her income in June is less than the MPW income maximum. There is no need to explore income for July and August as once eligible for MPW coverage continues through her post-partum period.
If the participant has requested coverage for all three prior quarter months and income for the first month of the prior quarter exceeds the MPW income maximum, then explore eligibility for the following month(s).
EXAMPLE: Ms. X applies February 24th and requests prior quarter. Prior quarter coverage can be explored starting with November 1st. Her income in November is more than the MPW income maximum. Explore December eligibility. If she is over income for December, explore January eligibility.
EXAMPLE: Ms. K applies November 12 with a due date of January 13 and requests coverage for all three PQ months. Her income varies from month to month. Her August income was $3000, her September income was $1000 and her October income was $2500, and her November income is $1000. Income will be budgeted as income received in each prior quarter month. She is over income for August, but is eligible on all factors in September. Approve coverage beginning September 1st and ongoing.
EXAMPLE: Ms. W applies October 4 and requests coverage for all three PQ months. Her estimated due date is June 14. Based on the statement, the beginning date of pregnancy is September 14. The prior quarter coverage can begin no earlier than September 1.
There is no need for the level of care (LOC) to remain the same throughout the coverage period. Eligibility for each month of prior quarter is determined individually. Therefore, a participant may be found eligible for different LOCs in different months of the prior quarter and for ongoing coverage.
EXAMPLE: Ms. M requests coverage and has medical bills for all three PQ months. She is eligible for an LOC of ME 18 in month one, over income in month two, an LOC of ME 45 in month three and ME 18 ongoing. Ms. M should be given ME 18 in month two to continue her eligibility for MPW into month three. Month three and ongoing provide her with continuous coverage even though they are different LOCs.
When the participant does not request coverage for all three prior quarter months
Because eligibility for each month of prior quarter is determined separately, a participant who requests and is eligible for MPW in the prior quarter may receive specific months of coverage based on eligibility and the months requested.
EXAMPLE: Ms. G requests coverage and has medical bills for month one in the PQ. She applies for current/ongoing coverage for current and future medical expenses, and she applies for month one in the PQ because of bills she received in that month. She is found eligible and is approved for PQ month one, and the month of application & ongoing.
If you cannot verify a need for coverage in the PQ period, evaluate for coverage beginning in month of application.
If all eligibility requirements are met, the pregnant woman is eligible for MO HealthNet benefits. If a second parent is in the home, they are not eligible for benefits under MO HealthNet for Pregnant Women.
Add a Pregnancy forms may be used to request pregnancy coverage for an individual that is included in an active MAGI case but is not receiving pregnancy coverage. A new application is not necessary.
Coverage begins with the first day of the month in which eligibility is met. This may be a prior quarter month as long as the applicant was pregnant in that month.
If a pregnant woman loses eligibility for any other MO HealthNet program a review should be completed to determine eligibility for MPW. She should be transitioned to MPW with no lapse in coverage.
Pregnant women approved for MO HealthNet benefits continue to be eligible during the postpartum period. For women who apply while pregnant, postpartum coverage terminates on the last day of the month containing the 60th day after the birth of the child or the pregnancy terminates.
Eligibility for postpartum only coverage is not provided by law. To be eligible for postpartum, the woman must have made application for MO HealthNet while pregnant and have been eligible, even though approval of the application may be after the birth of the child or the pregnancy terminates.
The postpartum end date is determined by expected delivery date when entered at the time of approval. Postpartum eligibility terminates on the last day of the month containing the 60th day after the termination of the pregnancy for women who apply while pregnant. The postpartum eligibility end date may be incorrect once the child is born or the pregnancy terminates. If we become aware of the birth or termination of pregnancy prior to postpartum ending, make corrections to the pregnancy evidence based on the actual pregnancy end date.
EXAMPLE: An application was approved with an expected delivery date of October 5 which resulted in a postpartum end date of December 31. The participant delivered the child on September 20. The ES must change the pregnancy evidence due date to September 20. As a result of this action MEDES will reassess the postpartum end date to November 30.
EXAMPLE: An application was approved with an expected delivery date of October 20 which resulted in a postpartum end date of December 31. The participant did not deliver the child until November 5. The ES must change the pregnancy evidence due date to November 5. As a result of this action MEDES will reassess the postpartum end date to January 31.
If a woman applies for MO HealthNet for Pregnant Woman after her pregnancy terminated, she may be eligible through the end of the month in which it terminated. Benefits would begin on the first day of the month of application or earliest month in the prior quarter in which she met all eligibility requirements. Due to continuous eligibility, her MO HealthNet benefit would continue through the last day of the month in which the pregnancy terminated.
NOTE: Women who apply for MO HealthNet for Pregnant Woman after the termination of their pregnancy are NOT eligible for Extended Women's Health Services (EWHS). Complete an ex parte review to determine eligibility for another MO HealthNet program. Refer to manual section 1890.000.00 EX PARTE REVIEW PROCESS.
Uninsured women between ages 18 and 55, who are in need of family planning services and will lose full MO HealthNet eligibility when their post-partum period ends, may remain eligible for Extended Women's Health Services (EWHS). EWHS continues for a maximum of one year after MPW eligibility expires.
NOTE: The need for family planning services is implied for EWHS. The individual does not have to request family planning services to qualify for EWHS.
NOTE: For insurance to cause ineligibility for EWHS, it must cover family planning services. (Example: Medicare covers family planning)
When coverage for this program ends, an ex-parte review is required. If no other eligibility exists when closing EWHS cases, the Eligibility Specialist must send an appropriate IM-33 notice.
Refer to manual section 1870.015.00 Healthcare Coverage for services covered by EWHS.
A woman receiving EWHS may qualify for another MO HealthNet program with more extensive coverage. If so, approve the other program and close the EWHS. Anytime the EWHS case is closed, the woman cannot regain eligibility for EWHS for the remainder of the one-year period.
If a woman becomes pregnant while the EWHS case is active it is necessary to enter pregnancy evidence into MEDES. Refer to Change in Circumstance in the MEDES Quick Reference Guide.
If the eligibility specialist (ES) becomes aware that the participant is sterilized, or if the participant requests the coverage be closed, end date the need for MO Family Planning Services evidence in MEDES and follow ex parte procedures.
EXAMPLE 1: Ms. Jones delivers her child March 25, by C-Section and notifies her ES that during her C-Section, she had her tubes tied. Upon notification, the ES ends the need for MO Family Planning Services evidence in MEDES. Ms. Jones is not eligible for EWHS and her coverage will end after the 60 day post-partum period.
EXAMPLE 2: Ms. Smith was put on EWHS after her 60 day post-partum period ended. Two months into her one-year period of EWHS, FSD is notified that Ms. Smith was sterilized. She is no longer eligible for EWHS.
The system will generate a letter to insured women advising when their postpartum benefits end and the reason they do not qualify for the one-year extension for women's health services. The letter has instructions to notify an eligibility specialist immediately if they no longer have health insurance. If contacted by a participant who states they no longer have health insurance, update the appropriate insurance evidence piece in MEDES immediately so the case transitions to EWHS. Participant attestation of insurance ending is acceptable.
Annual renewals are not required for MO HealthNet for Pregnant Women (MPW) cases.