BABY YOUR BABY PROVIDER’S MANUAL
TABLE OF CONTENTS
OVERVIEWS OF THE BABY YOUR BABY PROGRAM
The Presumptive Eligibility Program – Baby Your Baby
Baby Your Baby and the Enhanced Perinatal Services
LINE
BY LINE INSTRUCTIONS FOR COMPLETING THE BABY YOUR BABY APPLICATION AND CARD
Department of Workforce Services Extension Stamp of Baby Your Baby Cards
TRAINING
EXERCISES FOR COMPLETING BABY YOUR BABY APPLICATIONS
Determining Household
Size Exercise
Calculating Monthly
Income for Baby Your Baby
Determining Income
Exercise
Determination of the
Estimated Date of Delivery Without a Pregnancy Wheel
SAMPLES
OF THE BABY YOUR BABY APPLICATION AND BABY YOUR BABY CARD (PINK CARD)
Introduction
The Baby Your Baby Application in English – Front Side
The Baby Your Baby Application in English – Back Side
The Baby Your Baby Application in Spanish – Front Side
The Baby Your Baby Application in Spanish – Back Side
The Baby Your Baby Card (Pink Card)
How to Order Forms
Policy Clarification Regarding Women of Undocumented Citizenship Status
Baby Your Baby and Public Charge Issues
Presumptive
Eligibility / Baby Your Baby, Child Health Insurance Program (CHIP) and Primary
Care Network (PCN)
Pregnancy Testing of Minors
and Parental Consent for Local Health Departments
Information on Paternity Testing
Job Description of a Baby Your Baby Program Representative
Medicaid Contracted Health Plans and the Baby Your
Baby / PE Program
Medicaid Reimbursement Rates by Code and Provider Type
Medicaid Provider Type - Alpha & Numeric Listing
Procedure for Requesting a Certificate of Creditable Coverage from Division of Health Care Financing Medicaid
Medicaid Contact Information
Medicaid Health Program Representative (HPRs) Offices by Region
Medicaid Information Line – Access Now
DEPARTMENT
OF WORKFORCE SERVICES REFERRAL LIST BY ZIP CODE
WOMEN, INFANTS AND CHILDREN PROGRAM (WIC) CLINIC LOCATOR
(WIC QUICK LIST)
OTHER
HELPFUL BABY YOUR BABY FORMS
Introduction
Important Facts about Baby Your Baby and Medicaid - English
Baby Your Baby Y
Medicaid - Spanish
Welcome to Baby Your Baby! - English
¡Bienvenida al Programa Mime a Su Bebé! (Baby Your Baby)
REPRODUCTIVE
HEALTH PROGRAM PATIENT EDUCATION PAMPHLETS AND OTHER PATIENT INFORMATION
MATERIALS
Welcome to the Baby Your Baby Program! If you are new to the program, I hope you will find this manual helpful as you orient to the program. If you have been working with the program for many years, please take some time to look over this manual, as there are changes from time to time.
Baby Your Baby is actually a 2-pronged program. One portion of it is housed in the Health Promotion Program at the Utah Department of Health. This area is tasked with providing outreach to the public regarding the importance of early, continuous, quality prenatal care. You have probably seen or heard ads for the program on KUTV, radio stations, in various print media or even on billboards. This portion of the program houses the Baby Your Baby Hotline (1-800-826-9662), hosts the Baby Your Baby Website (www.babyyourbaby.org) and distributes various print materials including the Baby Your Baby Health Keepsake.
Baby Your Baby is also the more user-friendly name of the
Presumptive Eligibility Program for Prenatal Medicaid. This portion of the program assists women
needing financial assistance for prenatal care to be pre-screened for Prenatal
Medicaid through use of a 2-page application.
This screening process is done by numerous agencies around the state
known as qualified providers (QPs) of presumptive eligibility (PE) – Baby Your
Baby Offices. The Utah Department of
Health, Division of Community and Family Health Services have certified these
agencies via a memorandum of agreement (MOA) to provide onsite PE. However, clients may also be screened by
telephone in
This manual has been developed in an attempt to provide some
guidance for new Prenatal Program personnel.
It is a companion guide to the 68 minute Baby Your Baby Application
Instructions video dated
Thank you for your work on behalf of the program’s clients and best of luck!
Debby Carapezza, R.N., M.S.N.
Nurse Consultant, Reproductive Health Program
Reproductive Health Program
Utah Department of Health - CFHS
Phone: 801-538-9946
Fax: 801-538-9409
E-Mail: dcarapezza@utah.gov
Revised:
OVERVIEWS FOR THE BABY YOUR BABY PROGRAM
The Presumptive Eligibility Program – Baby Your Baby
The Presumptive Eligibility Program was introduced as a part
of the State’s Perinatal Program in 1987.
This program permits early entry into quality, continuous prenatal care
through provision of a “bridge” into the Medicaid Program. Its initiation was made possible through
changes in the federal Medicaid Program and the successful passage of the State
Perinatal Initiative allocating 1.7 million dollars of cigarette tax monies
annually for perinatal care in
To promote the program and educate Utah residents regarding the importance of early prenatal care and well childcare, a public outreach program known as Baby Your Baby was initiated. This program includes a hotline, public service announcements, and publication and distribution of perinatal literature including a health keepsake. This booklet, given free to all pregnant Utah women or to families with children age five and younger, helps educate them regarding the importance of regular and continuous prenatal and well child care and helps them to participate in the care.
Entry into the Presumptive Eligibility (PE) Program is facilitated by 25 Qualified Providers at approximately 55 sites throughout the state. Participation as a Qualified Provider (QP) in the program is restricted by federal mandate to sites receiving the following federal monies or participation in various federal programs as noted:
Ø Title V Maternal Child Health Block Grant Funds, or
Ø
Ø
Ø Stewart McKinney Homeless Act Funds (340), or
Ø Special Food Program for Women, Infants & Children (WIC), or
Ø Supplemental Food Program (Food Stamps), or
Ø Title V of the Indian Health Care Improvement Act, or
Ø Designation as an Indian Health Service site, or
Ø Designation as a health program or facility operated by a tribe or tribal organization under the Indian Self-Determination Act (PL93-638), or
Ø Designation as an agency participating in a statewide perinatal program
Additionally, the agency must be eligible for payment under the State Medicaid Plan and be determined by the State agency to be capable of making the determinations necessary for issuance of Presumptive Eligibility. Such sites are issued a Memorandum of Agreement (MOA) between their facility and the Utah Department of Health, Division of Community and Family Health Services. This document, while not providing direct financial support, permits the QP to receive Medicaid reimbursement for specific outpatient perinatal services. Application must be made to Medicaid as QP for both the site and appropriate personnel seeking Medicaid reimbursement for some services rendered under the PE Program.
Women generally access the system through referral to a QP site by their health care provider or via the Baby Your Baby Hotline. At the QP site, the woman is screened by appropriately trained clerical staff for program eligibility through the use of a two page form that screens for citizenship, intent to reside in Utah, gross family /household income for family size (the fetus is included as a family member), and confirmation of pregnancy. No documentation of the above is required except verification of pregnancy. Application for the program may also be made online at: www.utahclicks.org After an applicant electronically submits her online application, she calls the site to schedule an appointment to complete the process either in person or via phone.
PE eligible women are issued a temporary Medicaid card, known as a Baby Your Baby or Pink Card, that is valid until the last day of the month following the month of eligibility determination or until Medicaid eligibility is determined, whichever occurs first. If denied PE, a woman may reapply any time her income or other reason for denial changes. A woman may have only one period of presumptive eligibility during her pregnancy. The Baby Your Baby Card is valid only for Medicaid eligible, outpatient pregnancy-related services provided by any willing, Utah Medicaid provider. During the time the Baby Your Baby Card is valid, the woman makes formal Medicaid application at her local Department of Workforce Services Office (DWS). The period of presumptive eligibility may not be extended unless the DWS application coordinator, intake worker or caseworker determines it is necessary to permit processing of the formal Medicaid application. While awaiting a determination of her Medicaid status, the client may receive outpatient prenatal care using her Baby Your Baby Card.
A specifically trained registered nurse, social worker, licensed practical nurse, health educator, or other trained personnel may be available at the QP site to act as a perinatal care coordinator (PCC) or case manager to assist clients throughout the application process and to assure that clients access perinatal services. (For more information regarding the qualifications for perinatal care coordinators, contact Medicaid Provider Enrollment at 801-538-6155). Provision of other enhanced services noted at the close of the first paragraph is optional.
With appropriate documentation, portions of the PCC’s service are Medicaid reimbursable. Reimbursement for services rendered during the period of presumptive eligibility is via the Utah Department of Health, Division of Health Care Financing (Medicaid) at current Medicaid reimbursement rates utilizing the HCFA 1500. Even if the client is determined by DWS to be ineligible for Medicaid, claims for eligible services made using the Baby Your Baby Care prior to denial will be paid. Documentation of services and reimbursement rates, codes, etc. is established by Health Care Finance (Medicaid).
Women ineligible for PE and Medicaid due to undocumented status are encouraged to apply for Medicaid Emergency Services Program during the month preceding delivery. This program will reimburse only for hospital delivery expenses and physician/Certified Nurse Midwife services rendered at the time of delivery. No outpatient pre or postnatal services are reimbursed under the Emergency Services Program.
At the DWS, a review of the client’s formal Medicaid application is made. An asset test is utilized by DWS in determining Medicaid eligibility. If the client is determined by DWS to be eligible for Medicaid, the client specifies a primary care provider, or if she resides along the Wasatch Front, a Medicaid contracted Health Program, and a permanent Medicaid card is issued. If the client’s Medicaid application was for prenatal medical services only, once determined eligible, her coverage is continuous, regardless of income, until the last day of the month in which 60 days following termination of the pregnancy occurs. The infant is also Medicaid eligible for the first year of life. However, the mother will need to make application on her child’s behalf following delivery. As with presumptive eligibility, clients denied Medicaid may reapply if their circumstances change. Different requirements may apply to women participating in the TANF and/or Food Stamp Program.
Sites utilizing Title V Funds are required to report data on their PE clients to the Utah Department of Health, Division of Community and Family Health Services. Consultation is available upon request from the Reproductive Health Program’s nurse consultant. Agencies interested in applying as Qualified Providers in the PE Program are encouraged to contact the nurse consultant at the following address:
Reproductive Health Program Nurse Consultant
Utah Department of Health / CFHS – RHP
Phone: 801-538-9946
Fax: 801-538-9409
e-mail: dcarapezza@utah.gov
Updated 01/08-DAC
Baby
Your Baby and the Enhanced Perinatal Services
Baby Your Baby (BYB) is a program of the Utah Department of Health (DOH). Initiated in the late 1980s as the result of legislative mandates at both state and federal levels, Baby Your Baby is a statewide outreach program – including a hotline – that promotes early entry into quality prenatal care. The name Baby Your Baby has also come to be applied to the DOH’s presumptive eligibility (PE) program that acts as a bridge into the Medicaid Program for expectant women and includes a package of prenatal specific services known as the enhanced perinatal services.
Any woman needing prenatal services, but lacking the
financial means to obtain them, can call the Baby Your Baby Hotline at
1-800-826-9662. She is then referred to
the Baby Your Baby (BYB) site closest to her residence, generally the local public
health department or community health center.
The client calls this site for an appointment to be screened for the PE
Program. Application for the program can
also be made online at: www.utahclicks.org The client submits
her application electronically and then calls the selected site for an
appointment to complete the process either by phone or in person. Eligibility is based upon her family size
(including the unborn baby) and household income with the financial threshold
being 133% of the federal poverty guidelines.
The only documentation required at the time of application is
verification of the pregnancy. This can
be done by means of a urine pregnancy test at some sites or the woman can bring
written verification of her pregnancy from her health care provider if she so
desires. Undocumented women applying for the program are not reported to Bureau
of Citizenship and Immigration Services (BCIS formerly INS), however, to be
eligible, the woman must be
Once determined to be eligible for the program, the BYB site issues the client a temporary medical card, also known as a Baby Your Baby Card or Pink Card, which is valid for use by any willing Utah Medicaid provider. It covers outpatient, pregnancy related, Medicaid covered services such as routine antenatal visits, outpatient ultrasounds, NSTs, and emergency room visits for pregnancy related care. No in-patient services are covered by the card and no global fees can be billed using the Baby Your Baby Card. Pregnancy related pharmaceuticals are also covered but the determination of what is pregnancy related is up to the discretion of each pharmacist. The Baby Your Baby Card is not to be copied and placed in the client’s chart as one usually does with a regular Medicaid card. The client must present her Baby Your Baby Card each time she requests covered services.
During the time period the client has the card, she is to make a formal Medicaid application at the Department of Workforce Services (DWS). It is at the DWS Office that documentation of income, assets, citizenship, etc. is required. The temporary card is valid until one of the following happens: expiration of the card on the last day of the month following its receipt (the date listed on the upper right hand corner of the card) or until DWS either approves or denies the client’s formal Medicaid application - whichever of those events occurs first. Billing for the BYB Program is via Medicaid using HCFA 1500s or electronically. While using the Baby Your Baby Card a client’s Medicaid number is her social security number with a “V” at the end. Once the client has been approved for Medicaid, her Medicaid number is used for billing.
In addition to the covered services noted above, a package of “enhanced perinatal services” is also available to women during both their presumptive eligibility periods and once they have been issued regular Medicaid cards. These services are also available to pregnant women with Medical cards who did not enter Medicaid through the BYB Program. They are: perinatal care coordination (case management), pre and postnatal home visits, individual high-risk pre and postnatal nutritional counseling, group childbirth education, and pre and postnatal psychosocial counseling. These services are defined in Medicaid Information Bulletin, “Services for Pregnant Women” updated July 2003. Each service has specific definitions and limitations as to the number and length of visits and qualifications for personnel providing these services. Enhanced services are limited to the prenatal and postpartum periods. Medicaid defines the postpartum period as ending the last day of the month in which 60 days following delivery occurs.
Upon enrollment in BYB, some clients are assigned a perinatal care coordinator - an R.N., social worker, L.P.N., or health educator approved by Medicaid who helps the client access needed perinatal and social services and assists the client as she progresses through the Medicaid system. Services for perinatal care coordination (billing code T1017 – Perinatal Care Coordination) are billed in 15 minute units to a maximum of 4 units per 30 day billing cycle. Referral to the enhanced services is the responsibility of the perinatal care coordinator (PCC). It does not required written referrals from either the care provider or the PCC but is a verbal “touch base” with the PCC to promote coordination of the client’s care. The name of the client’s PCC can be found on the reverse side of her BYB Card in the lower right hand corner. If the client no longer has her BYB Card, ask where she got on BYB and speak with a PCC at that site. Even if a pregnant Medicaid client did not enter the system through the BYB, access to the enhanced services can still be obtained through the PCC at your nearest BYB site. The Hotline can help you determine the site most convenient for your practice. For women enrolled in a Medicaid contracted Health Plan, contact the specific Health Plan to determine their policy for accessing the enhanced services.
Under the enhanced services, home visits (billing code H1004 – At risk, enhanced service; follow-up home visit) are designed mainly for assessment of the home, mother and infant, for educational purposes, emotional support, lactation support, or to encourage the woman to continue in care. These visits, when performed by eligible providers, do not require pre-authorization and, if coordinated with the PCC, may be provided by a certified home health agency. This service is limited to 6 visits during a 12-month period but may not extend beyond the postpartum period. Home visiting for rehydration therapy does require preauthorization for women on PE and should be billed under another home visiting code not covered in this section. Contact Medicaid for further information.
Nutritional counseling (billing code S9470 – Nutritional counseling, Dietitian visit [Prenatal – Postnatal]) is limited to women at high nutritional risk during their pregnancies and postpartum period. It must be performed by a Medicaid eligible, registered dietitian. It is limited to 14 units (each unit equals 30 minutes) of individual counseling during a 12-month period not to extend beyond the postpartum period.
Childbirth education (billing code S9446 – Patient education, not otherwise classified, non-physician provider, group, per session) is limited to 8 classes of at least one hour in length during a 12-month period of time not to extend beyond the postpartum period. Classes can include education on pregnancy, preparation for labor and delivery, lactation, childcare, and parenting. It must be offered by individuals approved by Medicaid. Individual patient instruction does not qualify for reimbursement under this Medicaid category of service.
Psychosocial counseling (billing code H0046 – Mental Health Services [prenatal and postnatal], Not otherwise specified) during the pre and postnatal period is provided to clients with high psychological and social risks and is limited to 10 units of counseling during a 12 month period. Medicaid defines a unit of counseling as 20 to 50 minutes of therapeutic exchange between the client and therapist. It must be provided by therapists approved by Medicaid. In some areas of the state, psychosocial counseling for Medicaid clients has been contracted to county mental health programs. Check with the county mental health program in your area regarding their policy on accepting BYB Cards as reimbursement for this service.
For
more information on the Presumptive Eligibility Program or the enhanced
services contact either the Baby Your Baby Hotline (1-800-826-9662) or Debby
Carapezza, RN, MSN, Nurse Consultant, Reproductive Health Program; Utah Department
of Health-CFHS-RHP, PO Box 142001, Salt Lake City, UT. 84114-2001or call at
801-538-9946; Fax at 801-538-9409; or e-mail: dcarapezza@utah.gov.
Updated
01/08
LINE
BY LINE INSTRUCTIONS FOR COMPLETING BABY YOUR BABY / PRESUMPTIVE ELIGIBILITY
APPLICATIONS
For March 2007
Applications
Those items with an asterisk denote changes from the
previous applications.
General Instructions:
1. Before completing the Baby Your Baby / Presumptive Eligibility Application (BYB application), be sure it is the current application. The revision date is on the bottom of the back of the form. The current form was revised in March 2007. Use of older forms may result in erroneous denial of women as being over the income limits since the monthly maximum income standards are increased yearly when the federal poverty guidelines are changed.
2. If you are completing the form by hand, use a medium point black pen as this produces a better copy should the form need to be faxed.
3. Bear down; you are making 2 copies in addition to the original.
4. PRINT LEGIBILY! If Medicaid workers are unable to read BYB application and enter incorrect information into the computer, future claims for reimbursement may be denied since what was entered may not match what the billing provider reads on the applicant’s Baby Your Baby Card (Pink Card).
5. If you make a mistake, either white out the error and neatly print over it or draw a single line through the error and print the correction neatly above it.
6. NEVER give the form to the applicant to complete as her handwriting may be illegible and she may answer questions inappropriately.
Line-By-Line Instructions:
Applicant’s Name: Print the last name, first name and middle initial of the applicant.
This name is the full, legal name of the applicant on the day she is making her application. A woman can use a hyphenated last name. The name entered on the BYB application must be the name the applicant will use throughout her pregnancy at all agencies involved in her care: Medicaid, Department of Workforce Services (DWS), private provider’s office, hospital, pharmacy, etc. Use of another name may result in denial of Medicaid claims since the name from the BYB application is the only one entered into the Medicaid computer. Therefore, other names or variations of that name will not be recognized and claims not exactly matching that in the computer will be denied. If the client has previously been on Medicaid under another name, place her current legal name on the BYB application. However, since the Medicaid computer will have her former name attached to her social security number, the Medicaid workers at the Utah Department of Health will not be able to enter her into their computer. The client will need to immediately contact the DWS application coordinator / caseworker to change her name in the Medicaid computer to match her current legal name. This change cannot be made by the Medicaid workers at the Utah Department of Health who input the BYB application into computer.
Eligible From: This is the date the application is completed. BYB applications cannot be backdated. If an applicant has already incurred expenses related to her pregnancy prior to her date of application for BYB, she may apply for retroactive Medicaid payment for up to 90 days at the time she makes her formal Medicaid application. For prior prenatal expenses to be paid by Medicaid, the applicant must meet all Medicaid requirements for the months for which she is requesting assistance.
Eligible Thru: This is the last date the card is valid if the applicant fails to file a Medicaid application. A pregnant woman may only receive BYB from the date of her BYB application through the last day of the next month. For example: If a woman applies for BYB on March 18th, the last day her BYB Card (Pink Card) will be valid is April 30th. The applicant’s BYB eligibility will always expire on the last day of the following month regardless of whether she made her BYB application on the first day of the previous month or the last. The applicant’s period of eligibility is, therefore, a variable period of time based on when in the month she makes application. The Baby Your Baby worker cannot extend the expiration date. In certain instances the applicant’s Department of Workforce Services' caseworker can extend a BYB card. See instructions under “After Your Have Made A Medicaid Application”, #2 for instructions on extension of BYB cards. While the date the Baby Your Baby worker places on the card is always the last day of the month following the month of application, the applicant’s card is only valid until that date OR until the Department of Workforce Services makes a final determination on the her Medicaid application – whichever of those events occurs first.
SSN or Program Number: Enter the applicant’s social security number. This number followed by a “V” is what Medicaid enters into their computer as a unique identifier for the applicant. It is the number that providers seeking reimbursement for BYB services place on the HCFA 1500 for the applicant’s ID number. Applications cannot be entered into the Medicaid system and therefore claims for the applicant cannot be paid without a number that is or “looks like” a social security number. If an applicant cannot remember or does not have a social security number, a program number (“dummy number”) may be issued for her. A social security number is not required when obtaining a permanent residence card/green card. Therefore, an individual may be a qualified alien – lawfully admitted to this country - and have a “green card” but not have a social security card. Please do not use a tax ID number, the applicant’s child or spouse’s social security number. If unsure whether or not a non-citizen’s social security number is “real”, please issue a program number. A series of unique numbers has been issued to each BYB site for this purpose. They are NOT real social security numbers and SHOULD NOT BE UTILIZED FOR ANY OTHER PURPOSE - TO DO SO CONSTITUTES FRAUD. Please make sure the applicant is aware of this. The program numbers for your site should be in a folder or notebook at your agency. If you issue a program number, immediately record the number issued, the date and name of the applicant to whom it was issued. Failure to promptly record this information may result in one number being issued to 2 applicants. This results in denial of claims and a great deal of work to resolve billing issues. If you cannot locate your series of program numbers, please call the nurse consultant for the Reproductive Health Program at the Utah Department of Health.
Date of
Birth: Enter the date using 2
digits, i.e.,
Mailing Address: Enter the
applicant’s street address or post office box.
If applicable, note apartment number. If the
applicant provides a post office box for her mailing address, please be sure
she truly does reside in
City, State, and Zip Code: Self-explanatory.
Daytime
Phone #: Please indicate, if
possible, where the applicant can be reached during normal working hours (
1a. Are you a U.S. Citizen? If the applicant’s response is “YES”, continue on to #2. No written proof of this claim is required. If the applicant responds, “N0”, go to 1b.
1b. If you are not a
2. Do you live in
3. Are you on
*4. Are you now on the Child Health
Insurance Program (CHIP) or Primary Care Network Program (PCN)? A “YES” response to this question is an
automatic denial for Baby Your Baby.
Note at #17 the reason for denial from the back of the application (#7
under “IF YOU WERE DENIED BABY YOUR BABY”).
Do not issue the woman a Baby Your Baby Card (Pink
Card). CHIP does provide coverage for
prenatal services. As a result, if a
woman on CHIP is also placed on Baby Your Baby, claims for Baby Your Baby will
be denied. CHIP does not cover the
enhanced services: perinatal care coordination, pre/postnatal home visiting,
pre/postnatal psychosocial counseling, pre/postnatal individual nutritional
counseling or group childbirth education.
Neither does enrollment in CHIP assure medical coverage for the first
year of life for the newborn as Medicaid does.
Therefore, a woman already on CHIP, while denied Baby Your Baby, needs
to be referred back to her CHIP caseworker to determine whether enrollment in
Medicaid is more advantageous for her.
She does not need to complete a Medicaid application as one was
completed at the time of her CHIP enrollment and can merely be updated. While this is being done, the woman can
receive prenatal services under the CHIP.
PCN does not cover prenatal services beyond urine pregnancy testing;
however, enrollment in PCN does result in a denial for BYB. As with CHIP, have the PCN client contact her
PCN caseworker to see if, now that she is pregnant, she can qualify for Medicaid.
5. Have you been on Baby Your Baby before for this pregnancy? By federal regulation, a woman is only permitted one period of presumptive eligibility per pregnancy – that is, she can only be on Baby Your Baby once per pregnancy. Therefore, the response, “Yes, I have been on Baby Your Baby before for this pregnancy,” is an automatic denial. Note at #17 the reason for denial from the back of the application (#4 under “IF YOU WERE DENIED BABY YOUR BABY”). Do not issue the woman a Baby Your Baby Card (Pink Card). Check to see if the applicant has made a Medicaid application and encourage her to do so unless she had been denied and there has been no change in her status since that denial by the Department of Workforce Services. If the applicant had applied previously for Baby Your Baby but was denied, ask the reason for denial. If the applicant was previously over income or some other reason for denial that has changed since the previous application, she may now qualify. Continue with the screening process.
6. Do you have any health insurance? Having health insurance is NOT a reason for denial of Baby Your Baby. Medicaid is the payer of last resort. If the applicant has any insurance, it must be billed and reimbursement, if possible, or a denial of coverage obtained from that third party before Medicaid will pay. Therefore, information on insurance is included on both the Baby Your Baby Application and Baby Your Baby (Pink Card) to assist providers in billing the third party payer prior to seeking reimbursement via Medicaid. Complete as much information as possible indicated on the application regarding the applicant’s insurance. An applicant’s inability to provide all or even a portion of the information requested does not impact her ability to qualify for Baby Your Baby. When she makes her Medicaid application, she will be given time to obtain her insurance information.
7. How many people are in your household? Use the chart at the top of back of the application to determine household size. Only people living together are counted as household members. For example, if a 17-year old applicant does not live with her parents, they are not counted in the household. Be sure to use the correct side of the chart to determine family size. Use the left side of the chart for applicants 18 years old or older. Note that the applicant’s legal spouse is counted. Even if the father of the baby lives in the household, he is not counted in that household unless he is the legal spouse. Use the right side of the chart for an applicant younger than 18 regardless of whether or not she is married. Enter the number in the household on the front of the application in the blank at #7.
8. What is the total gross income (before deductions) that you expect to receive this month for all members of the household listed in question number 7? The gross income must include the items listed in “A” through “H”: earnings, social security income, unemployment insurance, child support, self-employment, veteran’s benefits, workman’s compensation, and contributions or gifts. Remember, if the resident is not counted in the household, neither is the income generated by that person unless he/she provides money as a contribution or gift or if it is provided as child support from a non-household member, i.e., child support from the father who is not residing in the household. When determining the income, determine the monthly income. Monthly income must be based on 4.3 weeks per month. Therefore, if an applicant provides you with a yearly figure, simply divide it by 12. If the income figure provided is for every two weeks, divide by 2 and then multiply by 4.3. If the applicant provides an hourly income figure, compute a weekly figure and multiply by 4.3. ($7.00 per hour X 30 hours per week X 4.3 weeks = $903 per month.) If you simply multiply by 4 you will be under counting the applicant’s income, as you will only be calculating the income for 48 weeks of the year. Multiplying by 4.3 provides the total for the entire 52 weeks in the year.
Place the total the gross income for all members counted in the household in #7 including all monies from the sources listed in “A” through “H” for the month of application on the line at #8.
9. Circle the household size and income below. Include the unborn child.
Under the column labeled household size, circle the number entered at question #7. Also, circle the monthly maximum income permitted for the household size. If the total gross income noted in #8 is greater than the monthly maximum income circled for the household size, the applicant is NOT eligible for Baby Your Baby. If the total gross income noted in #8 is the same as or less than the monthly maximum income circled for the household size, the applicant IS eligible for Baby Your Baby and you may continue on with the screening process.
10.
Does the applicant meet the
financial requirements for presumptive eligibility? Based on the information determined in #9,
indicate whether or not the applicant met the financial requirements for Baby
Your Baby. If the applicant is over the
allowable income level for her household size, note at #17 the reason for
denial from the back of the application (#5 under “IF YOU WERE DENIED BABY YOUR
BABY”). Do not issue the
woman a Baby Your Baby Card (Pink Card).
11. Is the applicant on WIC? All applicants regardless of whether or not they qualify for Baby Your Baby are to be referred to WIC if they are not already enrolled in that program. If they are already enrolled, simply respond, “YES”.
12. If NO, was the applicant referred to WIC? If the applicant is not enrolled in WIC, make her aware of the program and refer her to the office closest to her home. If you do not know where to refer the applicant, have her call the State WIC Office at 1-877-WIC KIDS. If the applicant is already enrolled in WIC, there is no need for a referral and respond “NO” to this question. If the applicant is not already enrolled in WIC, it is anticipated that the response to this question will be “YES”. Referring an applicant to WIC simply means that she has been made aware of the program. It is up to the applicant whether or not she chooses to enroll. WIC enrollment is not required to qualify for Baby Your Baby.
13. I have provided the answers to the
above questions. I swear that the
answers I have given are complete and correct.
The applicant needs to read this statement or, if unable to
read, have it read to her and then sign it.
If she is unable to write her name, have her make her mark (X)
and then sign as a witness that it was the applicant’s mark. Remember to have the applicant write in the
date after her signature. A minor may
sign this statement. If you are using a
computerized form, simply read the statement as “Are you (applicant’s name) and
do you swear that the answers you have given are complete and correct?” If she responds “Yes”, simply click the
appropriate “YES” box or write “YES” in the blank on the form. Medicaid reserves the right to obtain
reimbursement from the applicant if the information she provides is knowingly
false. If an interpreter was used, note
his/her name and, if employed by an interpreting service, the employing
agency. If the interpreter was a staff
member, friend or relative note the relationship to the applicant. If the
applicant denies that the information is complete and correct, she does not
qualify for Baby Your Baby. Do not issue
a Baby Your Baby Card (Pink Card). Note
at #17 the reason for denial from the back of the application (#8 “Other” under
“IF YOU WERE DENIED BABY YOUR BABY” Write in “denies answers are complete and
correct”). It is doubtful that many
applicants will fall in this category.
14. Does the applicant have a medically
verifiable pregnancy? To this point only the attestation of the
applicant (her word) has been necessary – no written proof of residency or
citizenship, income, etc. has been required.
However, the applicant’s pregnancy must be medically verified. Medical verification of pregnancy is a
positive urine HCG, an ultrasound of the fetus or hearing the fetal heartbeat. Home pregnancy tests are not accepted as
verification of pregnancy and neither is a urine specimen obtained from
home. The applicant must have a positive
pregnancy test from her health care provider or a qualified testing center (a
CLIA certified lab or a lab that has received a waiver from CLIA) and a written
statement on the agency’s letterhead with the applicant’s name, the date of the
test and the positive result. If the
applicant has a picture of her ultrasound with her name and the date of the
test, that also may be accepted. Only
appropriately trained medical staff may verify pregnancy through hearing the
fetal heartbeat. Be sure to keep a copy
of the positive test result and attach it to the pink copy of the application
unless the urine pregnancy test part of the applicant’s medical record that is
maintained in the same record with the Baby Your Baby application. Allow the applicant to retain her copy of the
positive test to use as pregnancy verification at the time of her Medicaid
application. Positive pregnancy tests
may be billed to Medicaid if the applicant is eligible for Baby Your Baby (PE). If the applicant has proof of pregnancy with
her as noted above or if it was verified onsite indicate, “YES”. If unable to verify the applicant’s
pregnancy, indicate “NO” for this question.
This is an automatic denial for Baby Your Baby. Note at #17 the reason for denial from the
back of the application (#6 under “IF YOU WERE DENIED BABY YOUR BABY”) and do not
issue the woman a Baby Your Baby Card (Pink Card).
15. If YES, Estimated Date of Delivery: This is the applicant’s due date. This information is not required but may be helpful to the applicant’s Department of Workforce Services (DWS) caseworker. If possible, enter the due date on the line. If the applicant does not know her due date it may be determined by using the first day of the applicant’s last normal period and determining her due date through the use of a pregnancy wheel. Spotting, very light or periods that are significantly different from the applicant’s usual periods don’t count as being a normal period. If you do not have access to a pregnancy wheel determine the applicant’s due date as follows: Take the date of the first day of the applicant’s last normal menstrual period and add 7 to it. If she has trouble remembering the date, try to have her relate it to a significant event – was it before or after Christmas? Was it before or after that big snowstorm? Was it before or after a vacation? etc. From that date count back 3 months. That is the applicant’s due date – one year later. If you are unable to determine her due date, leave the space blank. Remind the applicant that the due date that counts is the one her health care provider establishes. Ours is only an estimate to help out the DWS caseworker.
16. I certify that the applicant IS / IS NOT eligible for Baby Your Baby. If there have been no reasons for denial and you have verified the pregnancy, the applicant is eligible. If there have been any reasons for denial, she is NOT eligible. Place an “X” in the appropriate square. DO NOT issue a Baby Your Baby Card (Pink Card) to an ineligible applicant! Expenses incurred by the applicant through the use of a Baby Your Baby Card issued in error – especially if the pregnancy was not verified – are payable by the agency issuing the card in error.
17. If NO, indicate the number of the reason for denial from the list on the back. As previously stated, if the applicant is denied Baby Your Baby, by federal regulation, she must receive a written explanation for that denial. Therefore, every applicant denied Baby Your Baby must receive the yellow copy of the application with the number of the reason for her denial noted. All 7 reasons have been explained. There is a #8 “Other”. If the applicant is denied for a reason other than the 7 listed on the back of the application, please write in the reason in the blank on the back of the application and mark #8 on the front at question #17.
BABY YOUR BABY OFFICE:
At the bottom of the front of the application, PRINT the name of the agency completing the application, the name of the individual completing the application and the address and phone number where the worker completing the form can be contacted. This is a mandatory field. In case of errors, it is vital that the Medicaid workers entering the form into the computers can clarify issues and make needed corrections. Failure to complete this area results in many hours of lost time for Medicaid personnel.
THE BACK OF THE APPLICATION:
The Household size chart at the top of the page has already been explained. See the instructions for #7 for review if necessary.
Be sure to review the following instructions with all eligible applicants.
IF YOU ARE ELIGIBLE FOR BABY YOUR BABY:
Please see the online manual
for detailed instructions for the online system, Utah Clicks.
If the applicant’s Baby Your Baby Card (Pink Card) expires before the applicant makes her formal Medicaid application, another card cannot be issued and neither can the old card be extended. In this case, the woman will have to go to her Department of Workforce Services (DWS) to make her Medicaid application. She can try to arrange retro payment for expenses incurred in the interval between expiration of her Baby Your Baby Card and her Medicaid coverage - if she is determined eligible. Obviously, it is much easier for the applicant if she completes the Medicaid application process prior to expiration of her Baby Your Baby Card. Applicants needing only financial assistance for pregnancy-related expenses are probably best served by filing a Medical Services Only Application (Medicaid only “short form” numbered 66M) at the DWS. See “How to Order Forms” in the Table of Contents regarding this form. Applicants also needing food stamps, subsidized childcare or cash assistance (TANF) along with financial assistance for medical expenses should make application at the DWS on the Utah Department of Workforce Services Application for Financial, Medical, Food Stamp and Childcare Assistance form (DWS-OSD 61PP). You can provide these applications to your clients by downloading them from the DWS website at: http://jobs.utah.gov/opencms/forms/61APP.pdf for English and http://jobs.utah.gov/opencms/forms/61APP-SP.pdf for Spanish.
AFTER YOU HAVE MADE A MEDICAID APPLICATION:
1. You cannot use your Baby Your Baby Card after you have
been approved or turned down for Medicaid.
An
applicant should be informed that once the Department of Workforce Services has
made a decision on her Medicaid application she should no longer use her Baby
Your Baby Card. If she has been approved
for Medicaid, she should then use her Medicaid number. If it will be awhile before the Medicaid Card
is mailed, the applicant’s caseworker can issue a letter stating she is
eligible and giving her Medicaid number.
The Baby Your Baby Card should then be mailed back to the Baby Your Baby
Office whose name and address appear on the front of her Baby Your Baby Card
(Pink Card).
2.
If your Baby Your Baby Card is going to run out and you have
not been told whether or not you will be able to get on Medicaid, call the
application coordinator at the Department of Workforce Services before your
card expires.
An applicant, by federal regulation, may have only one period of
presumptive eligibility per pregnancy - that is one Baby Your Baby Card. If an applicant loses her card, she may
receive a duplicate but all of the information on it must match the original
card including the dates of eligibility.
If the applicant never filed a Medicaid application and her Baby Your Baby
Card has run out, she will have to make a direct Medicaid application as noted
above. Her expired Baby Your Baby Card
cannot be extended. If she has filed her
formal Medicaid application and her caseworker will be unable to make a
determination on it prior to its expiration, the Department of Workforce
Services (DWS) application coordinator or caseworker can extend the Baby Your
Baby Card by placing the authorized stamp on the right hand side of the front
of her card (see DWS Extension Stamp of BYB Cards at the end of these
line-by-line instructions). The
application coordinator or caseworker will only extend the Baby Your Baby Card
long enough to permit final determination of Medicaid eligibility. A Baby Your Baby worker CANNOT extend a Baby
Your Baby Card, as she does not know whether or not a Medicaid application has
been made and what its current status is.
Each Workforce Services Office has one stamp. It is usually in the possession of the
agency’s supervisor. If the supervisor
does not have a stamp, have him/her call the Utah Department of Health’s
Reproductive Health Program’s Nurse Consultant.