Eligibility Online Manual

M1202B Qualified Pregnant Women

Purpose: This section will assist in determining eligibility for Qualified Pregnant Women.

Current Policy Effective Date: July 1, 2018

Date Last Reviewed: July 1, 2018

Previous Policy: January 1,2014


1. Applicants Must Meet Basic Eligibility Factors

    • Refer to Section M600 for a description of all basic eligibility factors.

    • Applicants must be a U.S. citizen or a lawful present immigrant.

      • Applicants residing in the U.S. under the Deferred Action Childhood Arrival (DACA) act are not eligible for this program.

2. Applicants Must Meet Income Requirements

Countable income must be less than or equal to the Family MAGI income standard. Refer to Medicaid Table 1. Refer to Section M901 to determine if income is countable.

3. Applicants Do Not Have Resource Test

4. Benefits Begin The First Day Of The Application Month If Determined Eligible

Benefits begin on the first day of the application month, if eligible, and may continue through the 60 day postpartum period.

5. Applicants May Be Eligible For Retroactive Benefits

Applicants may receive retroactive Medicaid benefits if they incurred medical bills during any of the three months prior to application.

Both approved and denied applicants must be reviewed. Reviewer must verify and determine eligibility separately for each retroactive month to determine whether the case would have been eligible if an application had been made.

Retroactive benefits will not be authorized prior to the month pregnancy begins.

6. Non-Citizen Applicants Receive Limited Emergency Services

Pregnant women who are not a U.S. Citizen or a lawful present immigrant may receive emergency services, including labor and delivery. Refer to Emergency Services, Family & Children's Section M1205 for additional information.

7. Clients May Need To Cooperate With Child Support

Child support cooperation is required after the birth of the baby when the father is not in the home or when paternity has not been established, unless Good Cause is approved.

Clients must cooperate in establishing paternity and in obtaining medical support and payments. Clients must also cooperate in identifying and providing information to assist in pursuing third parties who may be liable to pay for care.

Unmarried women who give birth while on Medicaid will be required to cooperate with child support enforcement per birthing cost requirements in the statutes listed below.

8. Clients Are Waived From Cooperation If Good Cause Is Approved

Child support cooperation is not required if Good Cause is approved.

9. Clients Must Cooperate If Good Cause Is Denied

Clients may choose to do one of the following if Good Cause is denied:

    • Cooperate

    • Refuse to cooperate but receive medical assistance for the children

    • Withdraw the application

Clients not choosing to withdraw their application and still wanting medical assistance must be referred to Child Support.

10. Clients Must Be Reviewed

Clients must be reviewed within the 60 day postpartum period to determine continued eligibility under another Medicaid program to include Pregnant By Choice.

    • Send the Pregnant By Choice Questionnaire in the month of the estimated due date or upon notification of the baby’s date of birth.

    • The Have You Had Your Baby notice is sent 30 days after the due date when the birth of the child has not been reported.

Refer to Section M1403 for information on reviewing eligibility.

11. Clients May Lose Benefits

Pregnant Women benefits will close on the first day of the next month when any of the following occur (Refer to Section M1404 for additional information on closing cases):

    • Client has moved out of state.

    • Client enters a public institution, excluding the Geriatric Hall at the State Hospital in Evanston.

    • Client dies.

    • Client determined no longer eligible.

    • Client has not provided information on the date of birth of the newborn within the 60 day postpartum period.

    • Adults who do not cooperate with child support requirements will lose the 60 day postpartum benefit.


Defining Group: 42 CFR 435.116

42 CFR 435.170

Child Support: 42 CFR 435.610

W.S. 14-2-1008 & 42-4-122

Income: 42 CFR 435 Subpart K

Resources: 42 CFR 435 Subpart L

Clarifying Information:

Resource Transfer Provisions Do Not Apply.

The 60 day postpartum period begins in the month following the baby’s date of birth or estimated due date. For example, if the baby is born on September 15th, the postpartum period will end November 30th.

Worker Responsibilities:

Determining Countable Income

1. Refer to Section M901 for information on calculating income.

Determining Retroactive Benefits

1. Determine whether each approved or denied applicant incurred medical bills during any of the three months prior to the date of application.

Closing Case After the 60 Day Postpartum Period

1. Close the case after the 60 day postpartum period when the date of birth cannot be determined and one of the following occurs:

1A. Client has not completed and returned a review form. Refer to Section M1404 for more information on closing cases.


1B. Client has not provided the baby’s date of birth. Refer to Section M1404 for more information on closing cases

2. Send 15-day closure notice.