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Texas Medicaid Womens Health Program Provider Training and Information December 2010.

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Presentation on theme: "Texas Medicaid Womens Health Program Provider Training and Information December 2010."— Presentation transcript:

1 Texas Medicaid Womens Health Program Provider Training and Information December 2010

2 Page 2 WHP Provider Training Introduction Provider Base Provider Certification Program Eligibility Application Benefits Referrals Resources Program Updates

3 Page 3 Introduction What is the Womens Health Program? The Womens Health Program (WHP) provides low-income women with free family planning exams, related health screenings, and birth control through Texas Medicaid. In 2005, the 79 th 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 governments purpose for allowing family planning waivers is to limit federal expenditures for Medicaid-paid births.

4 Page 4 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. Introduction

5 Page 5 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).

6 Page 6 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.

7 Page 7 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.

8 Page 8 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.

9 Page 9 Eligibility For the purposes of the WHP application, a clients 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.

10 Page 10 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). Childrens 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.

11 Page 11 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.

12 Page 12 Income Eligibility Household Composition The budget group consists of the applicant, her spouse, and all mutual and non- mutual 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.

13 Page 13 Income Eligibility Converting income to Monthly Income: Use the income spreadsheet available at 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.

14 Page 14 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: sWorks/C/100/100.htm#secC-131 sWorks/C/100/100.htm#secC-131 This information typically changes annually in April. Please be sure to use the most updated chart.

15 Page 15 Application Women can fill out an application at the point of service delivery (participating doctors office), and receive services the same day. Providers can accept a womans 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).

16 Page 16 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).

17 Page 17 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 Childrens Medicaid ID letter. Active WIC Verification of Certification. Active WIC Voucher. Active WIC/EBT Shopping List. Income Verification

18 Page 18 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.

19 Page 19 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 For women born in Texas without a birth certificate, HHSC eligibility workers can attempt to verify citizenship. The application must include the womans first and last name, her maiden name, and her mothers maiden name. A U.S. Citizen Identification card (Form I-179 or I-197) Proof of Identity: Current drivers 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 or the screening tool at Citizenship and Identity Verification

20 Page 20 Application (May 2007 updates highlighted)

21 Page 21 Application (May 2007 updates highlighted)

22 Page 22 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.

23 Page 23 Effective Date WHP Effective date: A womans 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 20 th. When certified, her enrollment will be effective from January 1 st. 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.

24 Page 24 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 factorsi.e., smoking, obesity, exercise, they relate to choice of contraception. Family planning counseling and education, including the health benefits of abstinence. Birth control, except emergency contraception.

25 Page 25 Benefits A list of approved procedure codes can be found at the end of this presentation and at: 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.

26 Page 26 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.

27 Page 27 Resources 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.

28 Page 28 Resources Billing information and client eligibility verification information: 1-800-925-9126 General program information for clients and application status for clients and providers: 1-866-993-9972

29 Page 29 WHP Diagnosis Codes

30 Page 30 WHP Procedure Codes*

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