Post-Eligibility Reviews for Pregnant Clients

HCA Apple Health

PROVIDER ALERT

The Health Care Authority (HCA) wants to make you aware of a development that may affect the coverage of some Apple Health (Medicaid) clients who are pregnant.

HCA conducts regular reviews of enrolled Apple Health clients’ reported incomes to confirm they are eligible for the program. (Clients attest to their incomes when they apply, and we do post-eligibility reviews after they are enrolled in the program.) These reviews are required by the federal Centers for Medicare & Medicaid Services to ensure that state and federal Medicaid dollars are used only for those who are eligible for the program.

Beginning May 16, 2016, we will conduct post-eligibility reviews for Apple Health clients who are pregnant. If we determine that an Apple Health client was not income-eligible at the time of enrollment, her coverage will be closed. If a client was income-eligible at the time of enrollment, and went over the income standard during her pregnancy, she will remain covered.

What happens to clients whose coverage is closed?

We will refer affected clients to the Health Benefit Exchange to purchase a qualified health plan.

How will HCA notify affected clients?

We are committed to giving affected clients advanced and adequate notice by mail. We want to allow enough time for clients to make arrangements for continued care through their current providers, or alternate providers if necessary.

What does this mean for past services providers have offered?

This will not affect payment for past services. In addition, affected clients will not be assessed an overpayment for services received before their Apple Health coverage was closed.

How does HCA make the over-income determination?

HCA compares the client’s declared family income at the time of enrollment against data from the state Employment Security Department and other sources. If the comparison shows a client might be over income, we request proof of income to determine eligibility.  If the client does not provide proof of income or if proof of income shows the client was not eligible, we close the client’s coverage.

Who should providers contact with concerns?

As our partners in the delivery of services to these clients, we appreciate your understanding and the importance you place on providing the best quality of care possible.

If you have any questions or concerns about how this may affect you or your clients, please contact us at:

Health Care Authority Provider Relations
Phone: 1-800-562-3022
Email:  providerrelations@hca.wa.gov