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Issue Alert - Guarantee of Payment for Pregnant Women

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Date:

Jun 26, 2007

Program Area:

Medicaid PAM 107, PEM 657

Issue Summary:

Local health departments are responsible for completing the DCH-1164, Guarantee of Payment for Pregnancy Related Services, not Department of Human Services (DHS) staff.

Persons Affected:

Pregnant Medicaid (MA) applicants

For More Information:

Center for Civil Justice 320 S. Washington, 2nd Floor Saginaw, MI 48607 (989) 755-3120, (800)724-7441 Fax: (989) 755-3558 E-mail: info@ccj-mi.org

Michigan Poverty Law Program 611 Church Street, Suite 4A Ann Arbor, MI 48104-3000 (734) 998-6100 (734) 998-9125 Fax


Background

The Department of Community Health (DCH) guarantees payment for
the following pregnancy-related services when a pregnant woman is
determined eligible for the guarantee:
• Prenatal care.
• Delivery.
• Postpartum care services.

A pregnant woman, age 18 or older, is eligible for guarantee-of-payment when:
• She is a Michigan resident, and
• Her fiscal group’s net income does not exceed 185% of the poverty level.
The pregnant woman must be a Michigan resident. She is considered a Michigan resident if she:
• Lives in Michigan, except for temporary absence, and intends to
remain in Michigan permanently or indefinitely; or
• Entered Michigan with a job commitment or to seek employment.

Maternity Outpatient Medical Services (MOMS) is a health coverage
program operated by the Department of Community Health (DCH). MOMS provides prenatal and postpartum outpatient pregnancy-related services to women who are pregnant or recently pregnant and who are not eligible for Medicaid. MOMS is not a Medicaid program.
The MOMS coverage period is from the date of application, with a maximum of 45 days of coverage unless the individual receives Medicaid Emergency Services Only (ESO) eligibility. Medicaid ESO eligible women receive prenatal care for the entire pregnancy and medically necessary ambulatory postpartum care for 60 days after the pregnancy ends regardless of the reason.

What's Happening?

In the past, when a woman was eligible for guarantee-of-payment,the DHS worker was supposed to issue both of the following to her:
• An DCH-1164, Guarantee of Payment for Pregnancy-Related Services, and
• A list of Medicaid providers.
The DCH-1164 gives the pregnant woman authorization to receive
medical services related to her pregnancy from a Medicaid-enrolled
provider. The applicant presents the DCH-1164 to her Medicaid-enrolled provider. It assures immediate access to care by guaranteeing payment. The letter tells the provider:
• That payment for pregnancy-related services is guaranteed during
the woman’s pregnancy and for two months after the pregnancy
ends, and
• That the letter is only valid for 45 days from the issuance date, and
• That if the woman is MA eligible, Medicaid will provide reimbursement, or
• If the woman is not MA eligible, the Maternity Outpatient Medical Services Program (MOMS) will provide reimbursement (see PEM 657), and
• What outpatient prenatal and postpartum-related care is reimbursable.

Now, instead of it being the DHS worker's responsibility to issue the Guarantee of Payment letter, it belongs to the local health department.

What Should Advocates Do?

Remember that the standard of promptness for all pregnant Medicaid applicants is 10 days. If your client's application has not been processed within that time, request a hearing.

Finding Help

Most legal aid and legal services offices handle these types of cases, and they do not charge a fee.

You can locate various sources of legal and related services, including the free legal aid office that serves your county, at MichiganLegalAid.org.

You can also look in the yellow pages under "attorneys" or call the toll-free lawyer referral number, (800) 968-0738.

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