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Women

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Title: Leadership Briefing Outline Author: lcarruth Last modified by: HHSC Created Date: 12/3/2003 5:16:06 PM Document presentation format: On-screen Show – PowerPoint PPT presentation

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Title: Women


1
Womens Health Program
Overview Provider Training and Information
2
Table of Contents
  • Introduction
  • Benefits
  • Referrals
  • Eligibility
  • Application
  • Renewals
  • Billing
  • Prescription drugs

3
Introduction
4
Introduction
  • What is the Womens Health Program?
  • The Womens Health Program offers a limited,
    Medicaid-paid family planning benefit to women
    ages 18-44 with net incomes at or below 185
    percent of the federal poverty level (FPL).
  • The program is effective January 1, 2007.
    Applications will be accepted starting January 1,
    2007. No women will be enrolled prior to that
    date.
  • Benefits of the program include an annual family
    planning exam and choice of contraception for 12
    continuous months.

5

Introduction
  • All Medicaid providers are eligible to
    participate. There is no separate provider
    enrollment process.
  • Services will be provided on a fee-for-service
    basis, except for FQHCs, which will be paid as
    they are currently under the prospective payment
    system (PPS). Womens Health Program
    participants will not be enrolled in a Managed
    Care Organization (MCO), even if they live in an
    Medicaid MCO area of the state.
  • There is no cost-sharing, premiums, or co-pays
    for services provided by the Womens Health
    Program.

6
Benefits
7
Benefits
  • The Womens Health Program provides limited
    family planning benefits. It is not the full
    Medicaid package.
  • Specific benefits of the Womens Health Program
  • Comprehensive health history and evaluation
  • Gynecological exam and Pap smear
  • Screening for diabetes, sexually transmitted
    diseases, high blood pressure, cholesterol, and
    breast and cervical cancers
  • Assessment of health risk factorsi.e., smoking,
    obesity, exercise, etc.as they relate to choice
    of contraception
  • Family planning counseling and education
  • All contraception, except emergency
    contraception.

8
Benefits
  • Due to the limited nature of Womens Health
    Program, the following are not covered benefits
  • Mammography. Screens for breast cancer are
    limited to a Clinical Breast Exam (CBE)
  • Treatment for any conditions diagnosed during a
    Womens Health Program visit.
  • A detailed Provider Procedure Code list of
    allowable services under the Womens Health
    Program will be available online at the Womens
    Health Program webpage at www.hhsc.state.tx.us/wom
    enshealth.htm.

9
Procedure Codes
  • The following procedure codes are allowable
    benefits under the Womens Health Program

10
Procedure Codes
11
Procedure Codes
12
Procedure Codes
13
Referrals
14
Referrals
  • Referrals for primary care are required when
    medically necessary.
  • Treatment for conditions identified in the course
    of a family planning visit are not reimbursed by
    the Womens Health Program.
  • 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 Womens Health
    Program patient to another doctor or clinic that
    can treat them.
  • If you identify a woman who may have breast or
    cervical cancer, please refer them to the Breast
    and Cervical Cancer Program. For the location of
    a BCCC provider in your area call DSHS Breast and
    Cervical Cancer Control at 1-512-458-7796 or
    visit the BCCC web site for provider locations at
    http//www.dshs.state.tx.us/bcccs/locator.shtm.
  • Limitations
  • Referrals are limited to providers who do not
    perform or promote elective abortion or contract
    or affiliate with entities that perform or
    promote elective abortions.

15
Eligibility
16
Eligibility
  • Who is Eligible for the Womens Health Program?
  • Women aged 18-44 who
  • have a net family income at or below the 185
    percent FPL
  • are U.S. Citizens or certain eligible immigrants
  • reside in Texas and
  • do not currently receive full Medicaid benefits,
    CHIP, or Medicare Part A or B.
  • If all other criteria are met, women are
    eligible for the Womens Health Program if they
    apply the month of their 18th birthday through
    the month of their 45th birthday.
  • Womens Health Program participants will fill out
    a simplified one-page application. Applications
    will be available through the following
  • Participating family planning clinics and
    Medicaid provider offices
  • Local Health and Human Services offices
  • Participating WIC offices
  • Participating community-based organizations and
  • Online at http//www.hhsc.state.tx.us/womenshealth
    .htm.

17
Eligibility
  • 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
  • Household Expenses (if woman wants to claim
    expenses)
  • Citizenship
  • Identity
  • Adjunctive eligibility (if applicable)

18
Eligibility
  • 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.
  • Proof of Household Expenses (Optional)
  • Dependent care
  • Statement or a current bill from provider,
    current receipts, 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
Eligibility
  • 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 my obtain a
    birth certificate through www.cdc.gov/nchs/howto/w
    2w/w2welcom.htm.
  • For women born in Texas without a birth
    certificate, HHSC eligibility workers can 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 www.hhs.state.tx.us/medicaid/flye
    r.pdf or the screening tool at www.hhsc.state.tx.u
    s/womenshealth.htm.

20
Eligibility
  • Adjunctive Eligibility
  • A woman is adjunctively income-eligible for the
    Womens Health Program 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), or
  • Childrens Medicaid.
  • Proof of current participation in any of these
    programs means a woman has already proven her
    income eligibility for the Womens Health Program
    to the State.
  • She will still have to provide verification of
    citizenship and identity.

21
Eligibility
  • Proof of Adjunctive Eligibility includes
  • Current Childrens Medicaid ID letter
  • Active WIC Verification of Certification
  • Active WIC Voucher
  • Active WIC/EBT Shopping List

22
Example of documentation WIC Verification of
Certification
SAMPLE
23
Example of documentation WIC Voucher
24
Example of documentation WIC/EBT Shopping list
25
Eligibility
  • HHSC has developed an eligibility screening tool
    for providers to use to determine whether a woman
    may be eligible for the Womens Health Program.
  • This screening tool may be used on the phone when
    a woman schedules an appointment or in the
    office.
  • The screening tool will be available online as a
    downloadable web document so that providers can
    tailor it to fit their office needs
    (www.hhsc.state.tx.us/womenshealth.htm).

26
Womens Health Program Screening Tool (front)
27
Womens Health Program Screening Tool (back)
28
Income Determination
  • To determine income eligibility for women who do
    not have proof of adjunctive eligibility, you
    must determine
  • Household composition/size
  • Monthly income

29
Income Determination
  • 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 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 19 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 the father of the children and any
    mutual and non-mutual 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.

30
Income Determination
  • Converting income to Monthly Income
  • Since monthly countable income is the basis for
    determining eligibility, you will frequently be
    required to convert income to a monthly amount. 
  • To convert income, multiply
  • weekly amounts by 4.33,
  • biweekly amounts by 2.17 and
  • 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.

31
Income Determination
  • 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/TexasW
    orks/C/100/131.htm
  • This information changes annually. Please be
    sure to use the most updated chart.

32
Eligibility
  • Womens Health Program Effective date A womans
    enrollment in the Womens Health Program 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 the Womens Health
    Program 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 pended until receipt of that
    information, as long as a woman provides the
    missing information within 30 days from the file
    date, the effective date remains the same.
  • If there is missing information and the woman
    does NOT provide the missing information within
    30 days, she will be denied.

33
Eligibility
  • Womens Health Program Application Processing
  • State eligibility workers have 45 days to process
    applications.
  • If a provider faxes an application and all
    supporting documentation to the State on the date
    of service, HHSC anticipates this processing time
    will be much shorter because there is
  • Dedicated Womens Health Program eligibility
    staff, and
  • A simplified one-page application.
  • Application processing is dependent on caseload.

34
Example
  1. A 25-year-old woman schedules an appointment at
    her local family planning clinic.
  2. It is determined she is a U.S. citizen, a
    resident of Texas, and has a child on WIC.
  3. She is instructed to bring proof of WIC
    participation, identity, and citizenship.
  4. She brings the requested information to the
    appointment, and fills out a Womens Health
    Program application.
  5. She sees a provider that day and receives Womens
    Health Program services.
  6. The provider photocopies the womans
    documentation and faxes it with her application
    to the toll-free Women's Health Program fax
    number.

35
Eligibility
  • Once a woman is certified, she will receive a
    Medicaid Identification form (MedID) each month
    (Form H3087).
  • The Womens Health Program MedID will clearly
    indicate that it is for Womens Health Program
    services only.
  • In the event that a woman misplaces or does not
    receive her monthly MedID, she will be issued a
    temporary MedID (Form H1027-A), that is also
    acceptable as proof of Women's Health Program
    participation.
  • To receive a temporary MedID, a woman should
    contact the local HHSC benefits office. To locate
    the local HHSC benefits office, a woman may dial
    2-1-1.

36
Womens Health Program Medicaid Identification
(Form H3087)
SAMPLE
37
Womens Health Program Temporary MedID (Form
H1027-A)
Womens Health Program
SAMPLE
38
Application
39
Application
  • The Womens Health Program has its own one-page,
    simplified application to facilitate women
    receiving services.
  • Providers can order applications online
    mid-December 2006 at
  • http//www.dads.state.tx.us/news_info/publication
    s/handbooks/forms.
  • Click on Order Printed Forms link, fill out
    form, and email it to the listed email address.
  • Allow two weeks for delivery.
  • The application is also available online at
    www.hhsc.state.tx.us/womenshealth.htm for
    providers to download and print individual
    applications.
  • If a woman is adjunctively income-eligible and
    she has acceptable proof of participation in
    other gateway programs, she has to fill out the
    personal information and household demographic
    information sections of the application, but not
    the income section.
  • All applications must be signed by the applicant.

40
Womens Health Program Application (front)
Sample
41
Womens Health Program Application (back)
42
Application
  • Once an application is completed, fax only the
    front page of the application to the toll-free
    number included on the application. Please ensure
    the application is complete and signed.
  • Verification of income, expenses, or adjunctive
    eligibility, identity, and citizenship must also
    be faxed with the application. To minimize
    paperwork and the chance that verification will
    be lost, please photocopy the appropriate
    verification to fit on one sheet, if possible.

43
Renewals
44
Renewals
  • In the 10th month of a womans participation in
    the Womens Health Program, the TIERS eligibility
    system will check to see if she is currently part
    of a household participating in Childrens
    Medicaid, Food Stamps, or TANF.
  • If a woman is a member of a household
    participating in the above-listed programs, she
    is adjunctively eligible for continued
    participation in the Womens Health Program. She
    will be sent a one-page adjunctive eligibility
    letter explaining her status, and requesting her
    signature and return of letter if she would like
    to continue receiving Women's Health Program
    benefits.
  • If a woman is not currently a member of a
    household participating in these programs, she
    will be sent the simplified, one-page application
    and be instructed to apply again.

45
Billing
46
Billing
  • Womens Health Program Billing
  • Providers must verify if a woman has been
    certified for the Women's Health Program prior to
    billing, or the claim will be denied. If a claim
    is denied prior to certification, providers can
    resubmit claims once a woman is certified.
  • Providers have 90 days from service delivery to
    bill the Womens Health Program.
  • To verify that a woman has been certified for the
    Women's Health Program
  • Call the TMHP Contact Center at 1-800-925-9126
  • Check online at www.tmhp.com (click on Verify
    Eligibility link).
  • For more information on how to verify
    eligibility, please see the Medicaid Provider
    Procedures Manual, Section 4.1.1.

47
Billing
  • While there is a detailed list of what procedures
    are allowable under this program, Federally
    Qualified Health Centers (FQHCs) will only be
    reimbursed for two specific procedure codes
  • 99214, Office, Outpatient Visit
  • J7300, Intrauterine Copper Contraceptive
  • All other procedure codes will be marked as
    informational.
  • All other providers will bill on a per service
    basis.
  • Providers must bill on the appropriate claim form
    based on their provider type. Family planning
    agencies who also contract with DSHS for Title V,
    X, or XX must bill in an approved electronic
    format or on the Family Planning 2017 (Revised
    January 2005) claim form.

48
Prescription Drugs
49
Prescription Drugs
  • There is a list of federally approved
    prescription drugs and methods of contraception
    that are allowed under this program. All
    prescription drugs are limited to contraception.
  • Since Women's Health Program services may be
    provided prior to a womans certification in the
    program, a one-months supply of contraception
    may need to be provided through a Class D
    pharmacy or other arrangement.
  • Once a woman is certified in the program, she
    will receive a Womens Health Medicaid ID that
    she can present at a local pharmacy with a
    prescription, or she may continue to receive
    contraception through a provider Class D pharmacy.

50
For More Information
  • For more Women's Health Program information
  • Training materials, FAQs, procedure codes list,
    prescription drug list, outreach materials, and
    application available at www.hhsc.state.tx.us/wom
    enshealth.htm
  • Citizenship documentation list available at
    www.hhs.state.tx.us/medicaid/flyer.pdf
  • Billing information, client eligibility
    verification www.tmhp.com
  • Call the Womens Health Program office at
    1-866-993-9972.
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