†††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† ARTICLE 5

 

††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† SECTION 6

††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† ††††††††††††††††

†††††††††††††††††††††††††††††††††††††††††††††††† POSTPARTUM BENEFITS

 

1.        GENERAL

 

Sixty-Day Postpartum Benefits provide limited no share-of-cost (SOC) Medi-Cal coverage to eligible women following childbirth or termination of pregnancy for any reason.Those eligible will receive a restricted benefits Medi-Cal card that covers postpartum and pregnancy related services.Physicians are responsible for determining which services are pregnancy related.

 

ACWD 87-80

 

Women who continue to receive no share-of-cost Medi-Cal during the 60‑day postpartum period are not eligible to receive this special postpartum coverage as their regular Medi-Cal card covers these services.

 

Women eligible to SOC Medi-Cal during the postpartum period will receive a no-SOC restricted services postpartum Medi-Cal card.If SOC is met, a regular Medi-Cal card will be issued for other medical needs.

 

Eligibility for 60-day Postpartum Benefits is not conditional on other eligibility criteria being met.

 

 

 

 

2.        ELIGIBILITY CRITERIA

 

Eligibility is limited to women who have applied for, are eligible for, and who have received Medi-Cal benefits during their last month of pregnancy.

 

The following women are NOT eligible to receive a postpartum Medi-Cal card:

 

 

 

 

A.       Women who receive Medi-Cal in the month pregnancy ends as part of three-month retroactive coverage.

 

B.       Women who do not meet their SOC for the month pregnancy ends.

 

C.       Women who are eligible to, and receive, no-SOC Medi-Cal bene≠fits (including Minor Consent Services) the month pregnancy ends and during the 60-day postpartum period, as their regular Medi-Cal card covers these services.

 

 

 

 

3.        PERIOD OF ELIGIBILITY

 

The postpartum period begins with the last day of pregnancy and continues for 60 calendar days.Written confirmation of the last day of pregnancy is not required unless the worker has reason to question the date reported by the beneficiary.In this situation the worker will request medical verification.For cases in which the beneficiary cannot produce medical verification (e.g., a miscarriage early in the pregnancy), the worker will obtain an affidavit signed and dated by the beneficiary.

 

 

ACWD 88-18

 

 

ACWD 87-80

 

 

A.       Beginning Date of Eligibility

 

The beginning date of eligibility to no-SOC postpartum benefits will differ according to the beneficiariesí circumstances.

 

1)      Medically Indigent (MI) women, whose Medi-Cal eligibility is based solely on pregnancy, become eligible the first of the month following the month pregnancy ends.

 

2)      Medically Needy (MN) women whose Medi-Cal eligibility continues after pregnancy ends, but who have an SOC, are eligible to no-SOC postpartum benefits the first of the month following the month pregnancy ends.

 

 

 

 

††††††††††††††††††††††† These beneficiaries receive a no-SOC postpartum Medi-Cal card, and, if SOC is met, a full scope Medi-Cal card.

 

††††††††††††††††††††††† NOTE:††††† Women with an SOC must meet that SOC in the month pregnancy ends to be eligible for postpartum no-SOC cover≠age.They do not need to meet the SOC in months following the last month of pregnancy to receive no-SOC postpartum coverage.

 

 

 

 

3)      Public Assistance (PA)/Other PA recipients or MN women, who due to change in circumstances lose Medi-Cal eligibility or change from no-SOC to SOC status during the 60-day period of postpartum eligibility, are entitled to no-SOC postpartum benefits.Postpartum benefits are effective the first day of the first month in which Medi-Cal ineligibility or eligibility with an SOC occurs.

 

 

 

B.       Final Date of Eligibility

 

The eligibility period for no-SOC postpartum benefits is limited to 60 days from the last day of pregnancy.Benefits are to be discontinued the end of the month in which the 60th calendar day falls.

 

 

 

 

Examples:

 

              No-SOC (Aid Code 86) Medically Indigent

 

The beneficiary delivers her baby on October 5.She continues to be eligible for full scope Medi-Cal coverage for the entire month (i.e., until October 31) and is issued a regular Medi-Cal card.If the 10‑day Notice of Action is sent timely, her MI eligibility is discontinued October 31 and eligibility for the no-SOC postpartum program begins on November 1.As the 60th day from the last day of pregnancy falls on December 3, her eligibility for pregnancy relat≠ed and postpartum services ends December 31 (the end of the month in which the 60th calendar day falls).During this time she is issued a no-SOC postpartum Medi-Cal card.If she had delivered on October 2, the 60th day from the last day of pregnancy would have fallen on November 30, and her no-SOC postpartum eligibility would have ended on November 30.

 

 

 

 

 

 

              SOC (Aid Code 87) Medically Indigent

 

The beneficiary's last day of pregnancy is October 25, and she meets her SOC for October.The Notice of Action is sent on October 28, but due to the 10-day notice requirement, her eligibility for full scope Medi-Cal coverage with a SOC continues until November 30.She does not meet her SOC in November or December and is not issued the regular Medi-Cal card.She is still entitled to receive postpartum coverage and is issued a no-SOC postpartum Medi-Cal card for November and December, as the last day of pregnancy is October 25, and the 60th day following is December 23.Her no-SOC postpartum eligibility ends on December 31.

 

 

 

 

              Loss of Eligibility During the 60-Day Period

 

The beneficiary is four months pregnant.She, her husband, and their child are on AFDC cash assistance with cash-based Medi-Cal.On March 30, she suffers a miscarriage.On April 15, her child leaves the home and AFDC is discontinued effective April 30.She is eligible for 60‑day Postpartum Benefits because she had applied for, was eligible to, and had received Medi-Cal services during the last month of pregnancy.Postpartum eligibility continues regardless of whether other conditions of eligibility are met during the 60-day period.As the 60th day from the last day of her pregnancy falls on May 28, she is issued a no-SOC postpartum Medi-Cal card for the month of May only.

 

 

 

 

              Leap Year Disadvantage

 

The beneficiary delivers her baby on January 1.Her eligibility for full coverage continues through January 31.As the 60th day from the last day of pregnancy falls on February 29, her eligibility for postpartum benefits begins February 1 and ends February 29.The leap year works to her disadvantage.If she had delivered on January 1 in a non-leap year, the 60th day would have fallen on March 1, and she would have had an additional month of the postpartum program eligibility through March 31.

 

 

 

 

4.        COUNTY OF RESPONSIBILITY

 

When a woman who is eligible for postpartum benefits moves to a new county during the 60-day postpartum period, the original county is responsible for benefits issuance and case maintenance until the last day of the month in which postpartum eligibility exists.

 

 

 

ACWD 88-18


5.        NEW FOOTER:4/93; MPG Letter #209ISSUING POSTPARTUM BENEFITS ON ACTIVE SOC CASES

 

A.       For MN Women Who Receive SOC Medi-Cal in the Month Pregnancy Ends and Eligibility to SOC Medi-Cal Continues After Pregnancy Ends

 

1)      Send postpartum benefits NOA 731 as soon as verification is received that the client's SOC has been met for the month pregnancy ends and a certification date is entered or appears on MEDS.

 

 

 


 

2)      Complete the postpartum section of Form 14-28 DSS and forward the original to the MEDS clerk for issuance of postpartum Medi-Cal card(s).Aid Code 76 was established to designate those beneficiaries who are eligible to postpartum benefits. File the copy of Form 14-28 DSS in the case record on top of the most recent 278 LM.

MEM

Proc. 5G

 

3)      An NOA informing the client of discontinuance of postpartum benefits is not required as long as the client remains eligible to other Medi-Cal benefits the month following termination of postpartum benefits.

 

 

 

B.       For the Minor Who Receives Minor Consent Services With an SOC

 

Beneficiaries who receive minor consent services with an SOC and who meet the SOC in the month pregnancy ends are entitled to receive postpartum benefits.In this situation, the worker will advise eligible minors of the availability of postpartum benefits and that she must request the card each month during the postpartum period.

 

 

 

 

C.       For PA/Other PA or MN Women Who Do Not Have a SOC in the Month Pregnancy Ends, But Who Have a Change in Circumstances Resulting in Eligibility Continuing With a SOC During the 60-Day Postpartum Period

 

1)      Send a timely NOA informing the client of change to SOC. Additionally, send postpartum benefits NOA 749.

 

2)      Complete the postpartum section of Form 14-28 DSS and forward the original to the MEDS clerk for issuance of postpartum Medi-Cal card.File a copy of Form 14-28 DSS in the case record on top of the most recent 278 LM.

 

3)      An NOA informing the client of discontinuance of postpartum benefits is not required as long as the client remains eligible to other Medi-Cal benefits the month following termination of postpartum benefits.

 

 

 

 


6.        NEW FOOTER:2/89; MPG Letter No. 46ISSUING POSTPARTUM BENEFITS - BENEFICIARY NO LONGER ELIGIBLE TO FULL SCOPE OR RESTRICTED BENEFITS

 

When discontinuing full scope or restricted benefits and issuing postpartum benefits, the worker will take the following appropriate actions:

 

 


 

A.       Discontinuing the MI Woman Only - Case Remains Active

 

When the MI woman is discontinued (i.e., Medi-Cal eligibility was based on pregnancy) and the newborn is added to the case and/or other children remain active in the MFBU, the worker will take the following actions:

 

 

 

 

1)      Discontinue the MI woman using negative action code 016 on Line J of the 278 LM document.

 

2)      Generate postpartum NOA by entering code 016 on Line B of the 278 LM document.

 

3)      Complete postpartum section of Form 14-28 DSS.Forward the original to the MEDS Clerk for issuance of postpartum Medi-Cal card(s).

 

4)      Set a calendar tic for the last month of postpartum Medi-Cal eligibility.This tic will serve as a reminder to send a timely postpartum discontinuance NOA.

 

 

 

 

5)      The original 14-28 DSS will be returned to the worker once the MEDS Clerk has completed the on-line transaction for the final month of postpartum eligibility.Receipt of this form can serve as a worker reminder, in addition to the calendar tic, that it is the final month of eligibility.

 

††††††††††††††††††††††† Remove the copy of Form 14-28 DSS from the case record and replace it with the original Form 14-28 DSS.

 

6)      Send timely postpartum discontinuance NOA 736 in the final month of postpartum eligibility.

 

††††††††††††††††††††††† NOTE:††††† This NOA is not required if the woman becomes eligible to other Medi-Cal benefits prior to termination of postpartum benefits.

 

 

 

 

B.       Discontinuing the Entire Case

 

Following pregnancy, when an MI woman is no longer eligible to full scope or restricted benefits, and there are no other MFBU members (i.e., a newborn will not be added to the case and there are no other children receiving assistance), the worker will take the appropriate actions detailed below:

 

 

 

 

1)      For MI Women Not Eligible For Other Medi-Cal Benefits

 

a)        Discontinue the Medi-Cal case using negative action code 016.Complete postpartum eligibility NOA (generated by negative action code 016) and send to beneficiary.

 

b)        Follow instructions listed in 6.B.3), below.

 

 

 

 

2)      For No - SOC PA/Other PA (Including Edwards vs. Kizer Continuing Cases) or MN Women Whose Change in Circumstances Means Medi-Cal Eligibility Ends During the 60-Day Postpartum Period

 

a)        Discontinue the Medi-Cal case, using the appropriate discontinuance code, sending timely NOA.Additionally, send postpartum eligibility NOA 749.

 

b)        Follow instructions listed in 6.B.3), below.

 

 

 

 

3)      Actions on Discontinued Cases

 

a)        Complete postpartum section of Form 14-28 DSS.Forward the original to the MEDS clerk for issuance of postpartum Medi-Cal card(s). File the copy of Form 14-28 DSS in the case record on top of the closed 278 LM.

 

b)        Set a calendar tic for the last month of postpartum Medi-Cal eligibility.This tic will serve as a reminder to send a timely closing NOA.

 

c)        Retain the case record for the entire period of postpartum eligibility.

 

 

 

 

d)        Evaluate reported changes to determine if there is potential eligibility to ongoing Medi-Cal benefits.(Refer to Section 6 below for necessary actions to determine ongoing eligibility.)

 

e)        The original Form 14-28 DSS will be returned to the worker once the MEDS clerk has completed the on-line transaction for the final month of postpartum eligibility.Receipt of this form can serve as a worker reminder, in addition to the calendar tic, that it is the final month of postpartum eligibility.

 

 

 

 

††††††††††††††††††††††††††††††† Remove the copy of Form 14-28 DSS from the case record and replace it with the original Form 14-28 DSS.

 

f)         When no changes are reported during the postpartum period that would indicate potential eligibility to ongoing Medi-Cal, the worker will:

 

 

 

 

††††††††††††††††††††††††††††††† (1)††† Narrate this information in the closed Medi-Cal case;

 

††††††††††††††††††††††††††††††† (2)††† Send timely postpartum discontinuance NOA 736 in the final month of postpartum eligibility.File a copy of the financial folder under the NOA tab; and

 

††††††††††††††††††††††††††††††† (3)††† Forward the closed case to Record Library following the final month of postpartum eligibility.

 

 

 

 

4)      Ongoing Medi-Cal Eligibility Determination

 

††††††††††††††††††††††† When a postpartum recipient whose case has been discontinued reports information that indicates potential ongoing Medi-Cal eligibility, the worker must check the renewal date of the closed Medi-Cal case.If the renewal month has passed, the client will be referred to intake.

 

††††††††††††††††††††††† When the renewal month has not passed, the worker will complete an NOA indicating verifications necessary to determine ongoing Medi-Cal eligibility and date information must be returned.Additionally, the worker will send Form 16‑2 DSS and a postage paid return envelope.

 

 

 

 

 

††††††††††††††††††††††† Forms and requested verifications must be returned to the worker no later than the last day of the month in which eligibility to postpartum benefits ends.

 

††††††††††††††††††††††† A face-to-face interview is not required unless a reinvestigation is due.

 

††††††††††††††††††††††† The worker will then take the following appropriate actions:

 

 

 

a)        Ongoing Eligibility Exists

 

††††††††††††††††††††††††††††††† (1)††† Enter appropriate aid type and restate reinvestigation date on Form 278 LM, Line B, or enter new reinvestigation date if reinvestigation is being completed.

 

††††††††††††††††††††††††††††††† (2)††† Enter transfer code 406 on Form 278 LM, Lines E and J.

 

††††††††††††††††††††††††††††††† (3)††† Generate Medi-Cal eligibility NOA 770.

 

 

 

 

b)        Ongoing Eligibility Does Not Exist

 

††††††††††††††††††††††††††††††† When Form 16-2 DSS is returned and ongoing eligibility to Medi-Cal benefits does not exist, or the client does not return Form 16-2 DSS:

 

 

 

 

††††††††††††††††††††††††††††††† (1)††† Send denial NOA 771.

 

††††††††††††††††††††††††††††††† (2)††† Send a timely postpartum discontinuance NOA 736 in the final month of eligibility.

 

††††††††††††††††††††††††††††††† (3)††† Forward the closed case to Record Library following the final month of postpartum eligibility.

 

 

 

 

 

 

7.        POSTPARTUM SPECIALIST ACTIONS ON CLOSED AFDC CASES

 

This section establishes procedures to be followed by the Medi-Cal Postpartum Specialist when processing closed AFDC cases in which postpartum benefits are to be issued.

 

 

 

A.       AFDC Worker Actions

 

The AFDC worker will determine the month(s) of eligibility to postpartum benefits and complete Form 14-28 DSS.The case record, with Form 14-28 DSS attached to the outside, will be forwarded to the Medi-Cal Postpartum Specialist no later than five working days after the closing date of the AFDC case.

 

 

 

 

B.       Postpartum Specialist Actions

 

Upon receipt of referred closed AFDC cases, the Postpartum Specialist will:

 

1)      Enter worker # on Form 14-28 DSS.

The codes below are to "scrunch" this paragraph to keep text on one page.The functions used are "Letter & Word Spacing" - Shft-F8, 4, 6, 3, 3.Permission granted by DM.

2)      Forward the original copy of Form 14-28 DSS to the MEDS clerk for issuance of postpartum Medi-Cal card(s).File the copy of Form 14-28 DSS in the AFDC case record on top of the closed 278 LM.

 

3)      Generate postpartum eligibility NOA 749.File a copy in the AFDC financial folder under the NOA tab.

 

4)      Set a calendar tic for the last month of postpartum Medi-Cal eligibility.This tic will serve as a reminder to send a timely closing NOA.

 

 

 

 

5)      Retain the AFDC case record for the entire period of eligibility.

 

6)      Evaluate reported changes to determine if there is potential eligibility to ongoing Medi-Cal benefits.Refer to Section 7.C. below for necessary actions to determine ongoing eligibility.

 

7)      The original Form 14-28 DSS will be returned to the Specialist once the MEDS clerk has completed the on-line transaction for the final month of postpartum eligibility.Receipt of this form can serve as a worker reminder, in addition to the calendar tic, that is the final month of postpartum eligibility.Remove the copy of Form 14-28 DSS from the case record and replace it with the original Form 14-28 DSS.

 

 

 

 

8)      When no changes are reported during the postpartum period that would indicate potential eligibility to ongoing Medi-Cal, the Specialist will:

 

 

 

a)        Narrate this information on closed AFDC case record;

 

b)        Send timely postpartum discontinuance NOA 736 in the final month of postpartum eligibility.File a copy in the AFDC financial folder under the NOA tab; and

 

c)        Forward the closed AFDC case file to Record Library following the final month of postpartum eligibility.

 

 

 

 

C.       Ongoing Medi-Cal Eligibility Determination

 

When a postpartum recipient reports information that indicates potential ongoing Medi-Cal eligibility, the Specialist must check the renewal date of the closed AFDC case.If the renewal month has passed, the client will be referred to intake.

 

When the AFDC closed case renewal month has not passed, the Specialist will complete an NOA indicating verifications necessary to determine ongoing Medi-Cal eligibility and date information must be returned.Additionally, the Specialist will send Forms 16-2 DSS, MC 216, MC 217, and a postage paid return envelope.

 

Forms and requested verifications must be returned to the worker no later than the last day of the month in which eligibility to postpartum benefits ends.

 

 

 

 

A face-to-face interview is not required unless a renewal is due.The Specialist will then take the appropriate following actions:

 

1)      Ongoing Eligibility Exists

 

a)        Determine whether a closed Medi-Cal case file exists, or if a new file will be needed.

 

b)        Open the Medi-Cal case using the appropriate aid type.

 

c)        Enter reinvestigation date of the closed AFDC case on Line B, or enter new reinvestigation date if reinvestigation is being completed.

 

d)        Enter TRANSFER CODE 406 on 278 LM/LMB, Lines E and J.

 

 

 

 

e)        Generate Medi-Cal eligibility NOA 770.

 

f)         Photocopy Form CA-1 and other required forms and verifications from the AFDC case record.

 

g)        Forward the closed AFDC case to Record Library.

 

 

 

 

2)      Ongoing Eligibility Does Not Exist

 

††††††††††††††††††††††† When Form 16-2 DSS is returned and ongoing eligibility to Medi-Cal benefits does not exist, or the client does not return Form 16-2 DSS:

 

a)        Send denial NOA 771.File a copy in the AFDC financial folder under the NOA tab.

 

b)        Send timely postpartum discontinuance NOA 736 in the final month of eligibility.File a copy in the AFDC financial folder under the NOA tab.

 

 

 

 

3)      Forward the closed AFDC case to Record Library following the final month of postpartum eligibility.

 

 

 

8.        CARD ISSUANCE

 

Workers shall complete the postpartum section of Form 14-28 DSS, indicating the month(s) of postpartum eligibility.Form 14-28 DSS is then forwarded to the MEDS clerk.

 

Restricted postpartum Medi-Cal cards are issued by the MEDS clerk via an on-line transaction. The MEDS clerk will retain Form 14-28 DSS through the period of postpartum eligibility, and issue a card each month indicated by the worker on the form.

 

When a postpartum card is issued, MEDS will automatically post a special indicator of "P" in the first digit of the "Program Indicator" field which appears at the bottom of the Medi-Cal information screen.