Provider Manual - Show Me Healthy Women (SMHW)
Section 3 - Client Eligibility
Client Eligibility Guidelines
SMHW eligibility has three primary criteria: income level, health insurance status and age guidelines. Income guidelines are based on 250 percent of the federal poverty guidelines. The SMHW program reimburses only for services when there is no other funding source available. Women 21 to 64 years of age are eligible for services; some service restrictions apply by age category.
SMHW/WISEWOMAN Programs are the payors of last resort. Providers may call the program RPC for guidance.
Age Eligibility Includes 21 to 64-year-old Women
Some exceptions pertain to guidelines for services available to clients older than 64 based on insurance. Please see page 3.3 for further information.
Transgender Clients
- Screening and diagnostic services are available for male-to-female transgender clients who have/are taking hormones as long as they meet program eligibility guidelines.
- Screening services are available for female-to-male transgender individuals who have not yet undergone a complete hysterectomy or bilateral mastectomy because these individuals are genetically female.
- The CDC does not make a recommendation on routine screening with this population; transgender women are eligible under federal law to receive appropriate cancer screening.
- To determine the medical necessity of screening, the CDC recommends providers discuss the risks and benefits of screening with all eligible clients.
Income Guidelines
| Household Size | SMHW Annual | SMHW Monthly | SMHW Weekly | SMHW Hourly |
|---|---|---|---|---|
| 1 | $37,650 | $3,138 | $724 | $18.10 |
| 2 | $51,100 | $4,258 | $982 | $24.57 |
| 3 | $64,550 | $5,379 | $1,241 | $31.03 |
| 4 | $78,000 | $6,500 | $1,500 | $37.50 |
| 5 | $91,450 | $7,621 | $1,758 | $43.96 |
| 6 | $104,900 | $8,742 | $2017 | $50.43 |
| 7 | $118,350 | $9,863 | $2,275 | $56.89 |
| 8 | $131,800 | $10,983 | $2,534 | $63.36 |
| Each additional person, add: | $13,450 | $1,120 | $258 | $6.46 |
Clients must have an income at or below 250 percent of the federal poverty income guidelines. Adjusted gross income on tax return or net amount on pay stub determines income eligibility.
Insurance Status of Uninsured or Underinsured
Health Insurance Status++ |
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| ++ Women with full MO HealthNet (ME Code 05, ME Code E2) or Medicare Part B, POS or HMO health coverage are not eligible for services. Assess Mo HealthNet (ME Code 13) Permanently and Totally Disabled for level of coverage. |
Providers may use the Client Eligibility Agreement form to document the insurance status of the client. Copies of these forms are located on pages 10.6-.7, or download a copy here.
Current Breast or Cervical Cancer
- Women who are currently diagnosed with a breast and/or cervical cancer are not eligible for SMHW services. Women being currently treated for breast or cervical cancer are also not eligible for SMHW services. However, once cancer treatment is completed the client may return to SMHW for routine screenings as long as eligibility guidelines are met.
MO HealthNet (Medicaid)
- Women with MO HealthNet Managed Care coverage may be eligible for SMHW services if they are enrolled in the Extended Women’s Health Services/EWHS, Uninsured Women’s Health Services/UWHS, or have an unaffordable MO HealthNet spend-down. These women are eligible for screening/diagnostic services through SMHW. Extended Women’s Health Services/EWH’S and Uninsured Women’s Health Services does not cover diagnostic services. The woman must meet all SMHW eligibility guidelines.
- SMHW Clients who reach age 65 and older or women previously not enrolled age 65 and older do not qualify for BCCT.
Medicare
- Women enrolled in Medicare Part B are not eligible for SMHW services. Medicare Part B covers breast and cervical cancer screenings. Refer women with Medicare Part B coverage to providers who accept Medicare reimbursement.
- Women who meet SMHW/WISEWOMAN eligibility requirements and state they cannot pay the premium to enroll in Medicare Part B, or are not eligible to enroll in Medicare Part B, are eligible for SMHW/ WISEWOMAN screening services. If women are eligible to receive Medicare Part B benefits and are not enrolled, encourage them to enroll.
Insurance
- The client’s insurance must be billed first; when billing DHSS, include the insurance payment amount on reporting forms in the “Comments” section. SMHW will only reimburse up to the total amount allowed for the procedure per program guidelines. The total amount allowed and reimbursed by SMHW for each CPT code includes any payments received from insurance companies, not in addition to insurance payments.
- SMHW and WISEWOMAN are the payors of last resort.
- Women enrolled in prepaid/managed care and health plans (such as Health Maintenance Organizations [HMOs], Point of Service Plans [POS] and MO HealthNet Managed Care [formerly MC+]) are not eligible for SMHW/WISEWOMAN services.
For further guidance regarding clients with insurance, please see page 9.3.
Documentation and Certification of Client Eligibility
The client must sign a SMHW Client Eligibility Agreement form that is retained in the client’s record each year. (Download a copy of this form here or pages 10.6 [English] and 10.7 [Spanish])
Providers must obtain documentation of income, age eligibility and address, if available, on an annual basis and place a copy of the documentation in the client’s record. (Electronic or paper medical records are acceptable.)
The following may be used for proof of age and income. | |
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Age | Income |
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Once eligibility is determined, screening providers must verify eligibility on all reporting forms. To comply with the quality assurance policy, 50 percent of client records must contain proof of eligibility.
Provider must retain information in clients’ charts regarding the green history form, (pages 10.8 [English] and 10.9 [Spanish] or here, and review this information with each additional annual screening. Client records must be retained and available for seven years.
Free Transportation for Clients
Free transportation is available for SMHW/WISEWO MAN clients. Providers can request a travel voucher booklet by contacting Show Me Healthy Women/WISEWO MAN staff or the Regional Program Coordinator ( RPC) assigned to their area. All program services qualify for transportation services, including initial office visits, lab visits, follow - up diagnostic office visits, lifestyle education sessions, and annual evaluation screenings in the contracted counties.
Travel Voucher Instructions
Funds are available through SMHW and WISEWOMAN to cover the cost of transportation to help remove the barrier of access to care in receiving screening, diagnostic, and education services.
Transportation services are available in most counties and St. Louis City. Please call the RPC for assistance. See pages 3.8 and 3.9 for a complete list of transportation providers and their contact information. Services are available Monday through Friday, with charges based on urban or county trips and one-on-one or regular-route travel. When a client calls to make an appointment for a SMHW or WISEWOMAN screening or diagnostic, or education services, please ask her the following questions before making an appointment date and time for her:
Does the client need transportation?
If yes, explain that free transportation is available for SMHW participants. A transportation provider will pick her up at her home, take her to the appointment, and return her to her home. Check with the transportation provider in your area for the transportation schedule. Ensure the client’s appointment date and time coincide with the transportation provider’s schedule.
Secure client address and telephone number.
If the client does not have a telephone, ask for a neighbor’s telephone number or for another number where she can be reached. The transportation driver may not be familiar with the client’s address and may need directions to the residence.
Does the client need any special assistance?
If the client needs an assistant or helper, SMHW will pay for transportation for one extra person. The assistant or helper should be 17 years of age or older. If a disabled client needs more than one assistant, call SMHW for approval. If the client has special medical equipment such as a wheelchair or oxygen, please inform the transportation provider at the time of scheduling.
Travel Vouchers
Complete the travel voucher and include the facility name and site code number. The provider can mail or fax the completed travel voucher to the transportation provider including the date and time of the appointment. A copy of the voucher may be given to the client. The transportation provider will secure the client’s signature on pickup.
Cancellation
Notification of cancellation to the transportation provider is required to avoid a penalty charge to SMHW/WISEWOMAN for the cost of the round trip. Provide a one business-day notice to cancel a trip. Contact the transportation provider for questions related to transportation services. See page 3.8 and 3.9 for a complete list of transportation providers, service areas, and contact information. Address SMHW questions to the central office by calling toll-free at 866-726-9926 or 573-522-2845.