Ala. Admin. Code r. 560-X-14-.06

Current through Register Vol. 43, No. 1, October 31, 2024

Section 560-X-14-.06 - Plan First Waiver

(1) The Plan First Waiver program operates under an approved Section 1115(a) Research and Demonstration Waiver which includes Special Terms and Conditions. It extends Medicaid eligibility for family planning services to all females of childbearing age (19 through 55) and men (ages 21 or older) who do not have creditable health insurance coverage as defined by the Health Insurance Portability and Accountability Act (HIPAA) and who are not currently sterilized. The Medicaid income eligibility limit is income at or below 141% of the Federal Poverty Level (FPL) who would not otherwise qualify for Medicaid. A standard income disregard of 5% of the FPL is applied if the individual is not eligible for coverage due to excess income.

(2) The program represents a collaborative effort between the Alabama Medicaid Agency (AMA)and the Alabama Department of Public Health (ADPH).

(3) The Plan First Waiver program is officially known as the "Plan First Program."

(4) Enrolled Medicaid providers are eligible to provide family planning services but must also enroll as a Plan First provider by completing a Plan First agreement. Upon receipt of the signed agreement, Medicaid's fiscal agent will add the Plan First provider specialty code to the provider's existing record. Those providers that only perform tubal ligations and vasectomies (surgeons, anesthesiologist and outpatient surgical centers) do not have to enroll as a Plan First provider.

(5) The following are the eligible groups for the Plan First Waiver:

(a) Women 19 through 55 years of age who have SOBRA-eligible children (poverty level), who become eligible for family planning without a separate eligibility determination. They must answer yes to the Plan First question on the application. Income is verified at initial application and re-verified at recertification of their children. Eligibility is redetermined every 12 months.

(b) SOBRA poverty level pregnant women 19 through 55 years of age are automatically eligible for family planning services after 60 days postpartum without a separate eligibility determination if they meet all eligibility criteria. Income is verified at initial application and re-verified at recertification of their children. Eligibility is redetermined every 12 months.

(c) Other women age 19 through 55 who are not pregnant, postpartum or who are not applying for a child must apply using a simplified shortened application. An eligibility determination will be completed using poverty level eligibility rules and standards. Client declaration of income will be accepted unless there is a discrepancy. The agency will process the information through data matches with state and federal agencies. If a discrepancy exists between the client's declaration and the income reported through data matches, the client will be required to provide documentation and resolve the discrepancy. Eligibility is redetermined every 12 months.

(d) Men, ages 21 and older, desiring a vasectomy and who meet the income eligibility limit. An eligibility determination must be completed using poverty level eligibility rules and standards. Eligibility is determined for 12 months. Retro-eligibility is not allowed. If the individual does not receive a vasectomy within the 12-month eligibility period, he will have to reapply for Medicaid eligibility.

Newly awarded family planning recipients will receive a Medicaid plastic card based on the same criteria as other Medicaid recipients. Providers will be informed at the time of eligibility verification that services are limited to family planning only. If a recipient has received a plastic card in the recent past, another card will be sent only upon request.

(6) In order to be eligible for Family Planning Services an individual must:

(a) Furnish a Social Security number or proof they have applied for a Social Security number

(b) Be a female resident of Alabama age 19 through 55

(c) Be a male resident of Alabama 21 or older

(d) Meet citizenship and alienage requirements

(e) Have family income at or below 141% of the federal poverty level. A standard income disregard of 5% of the federal poverty level is applied if the individual is not eligible for coverage due to excess income.

(f) Cooperate in establishing third party medical benefits, and apply for all benefits to which she may be entitled

(7) Once determined eligible, a male will remain eligible for covered services for 12 months unless he is terminated from the waiver for one of the reasons listed below. A female will remain eligible for benefits until the termination of the waiver unless she disenrolls or is terminated from the waiver for one of the following reasons:

(a) The recipient's gross countable family income exceeds 141% of the FPL. A standard income disregard of 5% of the FPL is applied if the individual is not eligible for coverage due to excess income.

(b) The recipient does not reside in Alabama

(c) The recipient is deceased

(d) The recipient has received a sterilization procedure

(e) The recipient requests her family planning benefits be terminated

(f) The recipient is outside the family planning age limit of 19 through 55

(g) The recipient is eligible for Medicare benefits

(h) The recipient becomes eligible for another Medicaid program

(i) The recipient fails to cooperate with the Medicaid Agency in the eligibility process, receipt of services or Medicaid Quality Control Review

(j) The recipient is determined ineligible due to fraud, misrepresentation of facts, or incorrect information

(8) Medical services covered for the extended eligibles are limited to birth control services and supplies only. This can include, as applicable:

(a) Covered family planning birth control methods

(b) Outpatient tubal ligation

(c) Doctor/clinic visits (for family planning only)

(d) Vasectomies

(9) Eligible recipients can also receive HIV pre- and post-counseling visits

(10) Eligible participants have freedom of choice in the selection of an enrolled network provider.

(11) Eligible recipients can receive care coordination. Care coordination services are provided by licensed social workers or registered nurses associated with the Alabama Coordinated Health Network Program (ACHN) who have received training on the Plan First program. Medicaid enrolled providers can make referrals to the ACHN for care coordination services.

Ala. Admin. Code r. 560-X-14-.06

New Emergency Rule: Filed August 28, 2000; effective October 1, 2000. New Rule: Filed September 21, 2000; effective December 11, 2000. Amended: Filed November 8, 2001; effective December 13, 2001. Amended: Filed December 11, 2009, effective January 15, 2010. Amended: Filed November 12, 2013, effective December 17, 2013.

Amended by Alabama Administrative Monthly Volume XXXVI, Issue No. 08, May 31, 2018, eff. 6/25/2018.

Amended by Alabama Administrative Monthly Volume XXXVIII, Issue No. 03, December 31, 2019, eff. 2/14/2020.

Previous Rule, Educational Materials effective October 1, 1982. Amended effective December 10, 1987. Repealed effective August 12, 1992. Rule 560-X-14-.06 was move from Chapter 560-X-37 and replaced with Rule 560-X-37-.06 as per certification filed December 11, 2009; effective January 15, 2010.

Author: Jerri Jackson, Managed Care Operations

Statutory Authority: Section 1115(a); Sections 1902(a)(10)(b), (e) (5) and (6) of the Social Security Act.