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.