Alabama Administrative Code › Title 560 - ALABAMA MEDICAID AGENCY › Chapter 560-X-14 - FAMILY PLANNING › Section 560-X-14-.06 - Plan First Waiver

Current through Register Vol. 42, No. 9, June 28, 2024
(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.