Eligibility Requirements. To qualify for CAWEM, a person must meet all the nonfinancial and financial eligibility requirements for another medical assistance program, except the citizen/alien status and Social Security Number requirements. CAWEM applicants who are not documented (do not have a legal immigration status) are not required to declare or provide proof of their citizenship or immigration status.
Exception: There is no CAWEM eligibility under the OHP-CHP category or under HKC. If the basis for CAWEM eligibility is OHP-OPU, eligibility for CAWEM is subject to 461-135-1102.
Workers do not need to make a decision about whether the person is in need of immediate medical treatment or in need of labor and delivery services. Medical decisions are determined by the person's medical provider pusuant to the OHA administrative rules.
Individuals can apply at any time, not just when they have an emergent need. Once eligibility is determined and the case is opened, the redetermination period is the based on the corresponding medical assistance program; CAWEM recipients can be eligible for retroactive benefits if the corresponding medical assistance program includes retroactive medical benefits.
The client will get a medical ID good for emergency services each month. The following statement is on the medical ID:
Coverage is limited to emergency medical services. Labor and delivery services for pregnant women are considered an emergency.
At the end of the redetermination period, a new application is required.
To add a child born to a CAWEM mother to the benefit group, a new application in not needed. CAWEM clients do not need a Social Security number or verification that they have applied for one. A child born to a CAWEM mother is an assumed eligible newborn (AEN). Add the child's medical eligibility to the case using the AEN need/resource code.
Most clients will apply under the OHP-only program and use the OHP 7210 application. To do this, they can call the OHP central number, 1-800-359-9517. They return the completed application to 5503. If the application is 60 or older, 5503 will forward the application to the local office that serves the client's zip code.
Clients who are 65 years of age or older can apply under OSIPM-OAA. They must complete the SDS 539A application. A client under age 65 applying under OSIPM-AD would have to meet SSI disability criteria (PMDDT decision).
CAWEM Prenatal. Pregnant CAWEM clients may be eligible for expanded benefits if they live in one of the following 14 counties: Benton, Clackamas, Columbia, Crook, Deschutes, Douglas, Hood River, Jackson, Jefferson, Lane, Morrow, Multnomah, Union or Wasco. The CAWEM prenatal program uses case descriptors “CWM” and “CWX” and need/resource code “CWX” with the due date.
For more information on the CAWEM prenatal program, please see SS-IM-11-042 or the Pre-Natal CAWEM training material PowerPoint: http://www.dhs.state.or.us/caf/caf_ss_medical/pre-natal_14_counties_cawem_Lane.pdf
Benefits. Clients are only eligible for emergency medical, including childbirth. Diagnostic services and on-going medical treatment, including prenatal and postnatal care, are not covered. Clients are not eligible for OHP-Plus, OHP-Standard or long term care benefits.
Retroactive Benefits. Whether or not retroactive benefits can be provided depends on which program the client applies under. There are no retroactive benefits under the OHP-only program. Retroactive benefits are possible under the OSIPM programs.
Coding. Use the AD or CH in-grant code, as appropriate. Open medical according to the request date. Use the CWM case descriptor for each person qualifying under the CAWEM program.
Hospital Holds. Hospital holds are handled in the same way they are for other Medicaid programs. The hospital calls or faxes the request to either the OHP central number or the local office to establish the date of request.
Claims Payment. Providers submit claims in the same manner as they do for other Medicaid programs. Only claims for emergency services can be paid. DMAP plans follow-up claims reviews to identify and correct providers' misunderstandings of the state's definition for emergency services.
To qualify for CAWEM, individuals must be residents of Oregon with the intent to remain in Oregon. There is no minimum amount of time a person must live in Oregon to be a resident.