Revision 13-4; Effective October 1, 2013

CHIP, CHIP Perinatal

Provide Form TF0001, Notice of Case Action, by the:

• 45th day after the file date for an application requesting health care for children.
• 15th working day after the file date for an application requesting health care coverage for a pregnant woman.

 

D—231 CHIP Perinatal Application

Revision 18-1; Effective January 1, 2018

CHIP Perinatal

Pregnant women who apply for medical assistance are screened for Pregnant Women Medicaid (TP 40). If ineligible for Medicaid, pregnant women under age 19 are tested for CHIP. If ineligible for CHIP because of age, income, or immigration status, pregnant women are tested for CHIP perinatal.

Women certified on CHIP perinatal due to not meeting immigration status requirements and whose household income is at or below Medicaid for Pregnant Women income limits at the time of application must submit Form H3038, Emergency Medical Services Certification, or Form H3038-P, CHIP Perinatal – Emergency Medical Services Certification, to cover the costs of labor and delivery.

Accept the applicant’s (pregnant woman’s, case name’s or authorized representative’s) verbal or written statement of pregnancy, including the start month, number of children expected and the anticipated date of delivery, unless questionable. The woman’s statement would be considered questionable if the information provided regarding the due date is discrepant, such as the pregnancy start month and pregnancy end month are less than or more than nine months apart or if the woman reports a pregnancy with overlapping start and end months.

If questionable, verify the applicant's pregnancy by using:

• Form H3037, Report of Pregnancy; or
• other documentation containing the same information as Form H3037.

The verification must be from an acceptable source such as a physician, hospital, family planning agency, or social service agency.

A physician, nurse, advanced nurse practitioner or other medical professional must sign Form H3037 or another document for it to be considered verification from a medical source. If it is completed by another medical professional, ensure that the information about the supervising physician is provided.

The application contains a field for the number of children expected and the anticipated date of delivery, but does not contain a field for the applicant to enter the pregnancy start month. Staff must use the following procedures when certain information regarding pregnancy is left blank on any application for benefits:

• If the only item missing on the application form is the pregnancy start month, staff must count nine months back from the pregnancy end month to determine the pregnancy start month. The pregnancy end month is month zero.
• If the only item missing on the application form is the pregnancy end month, staff must count nine months from the pregnancy start date to determine the anticipated date of delivery. The pregnancy start month is month zero.
• If both the pregnancy start and end months are missing, attempt to obtain the information by phone. If unable to obtain the information by phone, send Form H1020, Request for Information or Action, to request the information.

If the pregnancy verification is not received by the 15th workday from the request, deny the application. See D-220, Reopening an Application, if the verification is provided after the application is denied.

Related Policy

Pregnancy, A-144.5

 

D—231.1 Minor Pregnant Women with Potential Medicaid Eligibility

Revision 13-4; Effective October 1, 2013

CHIP, CHIP Perinatal

If an application is received for a minor pregnant woman, request all missing information and test for potential Medicaid eligibility.