1305.000.00  ELIGIBILITY CRITERIA

IM-111, November 26, 2007

To qualify for MO HealthNet based on the need for Breast or Cervical Cancer Treatment (BCCT), the following eligibility criteria must be met:

There are no income or resource limits for the BCCT program.

NOTE: To be eligible for a SMHW screening paid for by the SMHW program a woman must have income below 200% of the federal poverty level. It is the SMHW provider's responsibility to determine eligibility for the screening. The income limit is only for the screening, not for BCCT MO HealthNet eligibility. If a woman received a SMHW screening, she is eligible for BCCT MO HealthNet (if eligible on all other factors). FSD does not evaluate income at the time of the screening or as changes occur.

1305.005.00 SOCIAL SECURITY NUMBER

IM-111, November 26, 2007

This eligibility factor applies to BCCT applicants and is the same as for MO HealthNet for Families (MHF). Refer to Section 0905.010.05.

1305.010.00 CITIZENSHIP/ALIEN STATUS

IM-#54 July 21, 2009IM-111, November 26, 2007IM-#31 April 6, 2007IM-#66 June 23, 2006

The requirement is the same as for MHF. Refer to Section 0905.010.30.

1305.015.00 RESIDENCE

IM-111, November 26, 2007

The requirement is the same as for MHF. Refer to Section 0905.010.25.

1305.020.00 AGE / SEX

IM-111, November 26, 2007

To qualify for BCCT, the applicant must be a female under 65.

1305.025.00 SCREENING/DIAGNOSIS

IM-120, December 18, 2007IM-111, November 26, 2007

To be eligible for BCCT a woman must have been screened through the SMHW program and found to be in need of treatment for breast or cervical cancer. The screening and diagnosis may be done by either a DHSS contracted SMHW provider or a MO HealthNet provider. A local SMHW provider or MO HealthNet provider provides verification of eligibility on this factor. The screening may be verified by:

NOTE: A screening by a MO HealthNet provider only qualifies the woman for BCCT coverage, if the woman was an active MO HealthNet participant at the time of the screening/diagnosis.

The screening may have occurred prior August 28, 2001. A screening prior to August 28, 2001, qualifies a woman on this factor as long as she is still in need of treatment as a result of the screening. While the screening may have occurred prior to August 28, 2001, MO HealthNet coverage cannot begin prior to August 28, 2001.

To have the screening paid for through DHSS SMHW program, a woman must meet DHSS eligibility requirements for a screening. Currently these are that a woman be between the ages of 35 up to 65, be uninsured, and have income of less that 200% of the federal poverty level (FPL). Women not meeting these requirements can be screened by a SMHW provider in order to determine eligibility for BCCT coverage if they are active MO HealthNet participants at the time of the screening, but the cost of the screening cannot be paid for through DHSS SMHW program.

NOTE: Only SMHW providers who have signed a SMHW Participation Agreement with the Department of Health and Senior Services (DHSS) may determine Presumptive Eligibility for BCCT. The DHSS is responsible for insuring a provider meets the criteria necessary to qualify as a SMHW provider. If a woman received Presumptive Eligibility for BCCT, she is eligible for BCCT (if eligible on all other factors). FSD does not evaluate income at the time of the BCCT application or as changes occur.

1305.025.05  SMHW PROVIDERS

IM-120, December 18, 2007IM-111, November 26, 2007

SMHW providers are providers who have signed a SMHW Participation Agreement with the Department of Health and Senior Services (DHSS). These providers may determine Presumptive Eligibility for BCCT.

A list of SWMH providers that currently provide assistance with the cost of screenings for those income-eligible for BCCT Presumptive Eligibility determinations can be found at http://health.mo.gov/living/healthcondiseases/chronic/showmehealthywomen/providerlist/.

NOTE: A diagnosis of breast or cervical cancer by a MO HealthNet provider, including MO HealthNet Managed Care provider, is considered a SMHW screening for the purpose of establishing eligibility for BCCT coverage for women who are active MO HealthNet participants at the time of the diagnosis.

1305.030.00  NEED FOR TREATMENT

IM-111, November 26, 2007

“Need for treatment” means, in the opinion of the woman's treating health professional, the diagnostic test following a breast or cervical cancer screening indicates that the woman is in need of cancer treatment services. These services include diagnostic services that may be necessary to determine the extent and proper course of treatment, as well as definitive cancer treatment itself. Treatment services also include treatment services for certain pre-cancerous conditions. However, women who are determined to require only routine monitoring services for a pre-cancerous breast or cervical condition (e.g., breast examinations and mammograms) are not considered to need treatment.

Need for treatment is considered verified by the SMHW provider's decision for three months from the diagnosis date (or PE decision date). After the initial three-month period, certification of the continued need for treatment and estimated length of treatment must be obtained from the treating physician by use of the BCC-2. Priorities should be set to obtain a physician's certification at the end of the initial three-month period and in the month it is estimated a course of treatment will be completed. Do not assume that treatment is no longer needed without requesting a new certification from the treating physician.

When a BCCT participant is due for a physician's certification, request that she provide the name of her treating physician and sign a release of information to obtain the certification. Send the signed release of information and a BCC-2 to the treating physician. The process is similar to requesting medical information to determine eligibility for MO HealthNet based on disability, except that a Medical Review Team (MRT) decision is not required.

Women screened through a SMHW provider who determined Presumptive Eligibility for BCCT will have a case manager based at one of the 7 regional BCCCP (FSD  Intranet Tools) or Department of Health (DOH) offices.  When a certification of continued need for treatment is needed, it may be helpful to contact the case manager to request their assistance in obtaining the information.

1305.035.00  UNINSURED

IM-111, November 26, 2007

To be eligible for BCCT, a woman must be uninsured. Health insurance is defined as insurance that minimally provides coverage for physician's services and hospitalization. It must also cover breast and cervical cancer treatment. There is no penalty or waiting period for dropping insurance.

Health insurance does not have to cover all medical conditions (such as pre-existing conditions) to cause ineligibility for BCCT, however it must cover breast and cervical cancer treatment services. A woman with insurance that does not cover breast or cervical cancer treatment is considered uninsured.

The term “health insurance” does not include short-term, accident, fixed indemnity, limited benefit or credit insurance, coverage issued as a supplement to liability insurance, insurance arising out of a worker's compensation or similar law, automobile medical payment insurance, or insurance under which benefits are payable with or without regard to fault and which is statutorily required to be contained in any liability insurance policy or equivalent self insurance.

Women who have exceeded a lifetime maximum for all benefits under their health plan are considered uninsured. If a woman has exceeded an annual maximum or the maximum for one particular service (other than breast or cervical cancer), she is considered insured. The applicant must provide documentation they have reached their lifetime maximum for all benefits.