Attachment 2 995 Option a selectPlan for Women – Elig: psf only App




Yüklə 13.48 Kb.
tarix14.04.2016
ölçüsü13.48 Kb.

ATTACHMENT 2



995 - Option A SelectPlan for Women – Elig: PSF Only App

You are eligible for SelectPlan for Women (family planning services). A PA ACCESS card will be mailed to you unless you have one. If you have any questions or changes to report, please contact the Department of Public Welfare's Office. The box above lists how to contact the Office. When contacting the Office, please provide your record number. It is located in boxes at the top and bottom of this notice.


Citation: 55 PA Code 181.1, Pennsylvania's Family Planning Waiver 12/29/05,

Section III, 3.2


995 - Option B SelectPlan for Women – Elig: MA App

You are eligible for SelectPlan for Women (family planning services). A PA ACCESS card will be mailed to you unless you have one. If you have any questions or changes to report, please contact the Department of Public Welfare's Office. The box above lists how to contact the Office. When contacting the Office, please provide your record number. It is located in boxes at the top and bottom of this notice.


Your application for other Medical Assistance benefits has been reviewed. Based on the information that you provided, you do not meet the eligibility requirements for any other Medical Assistance benefits. If you have questions, please contact your caseworker.
Citation: 55 PA Code 181.1 & 178.1; Pennsylvania's Family Planning Waiver

12/29/05, Section III, 3.2


995 - Option C SelectPlan for Women – Elig: Post Partum PS16 to PSF

You are eligible for SelectPlan for Women (family planning services). These services begin after the closing of your Medical Assistance coverage at the end of your post-partum period. Please use the PA ACCESS card that you have to pay for these services. If you have any questions or changes to report, please contact the Department of Public Welfare's Office. The box above lists how to contact the Office. When contacting the Office, please provide your record number. It is located in boxes at the top and bottom of this notice.


Citation: Pennsylvania's Family Planning Waiver 12/29/05, Section III, 3.2
995 - Option E SelectPlan for Women - Inel/Stop/Disc: Income

Your income exceeds the SelectPlan for Women (family planning services) program income limit. To qualify for family planning services your income cannot exceed the 185% of the Federal Poverty level. Refer to section B on the reverse side of this notice for information on the income used in this determination.


Citation: PA 55 Code 181.1; Pennsylvania’s Family Planning Waiver 12/29/05, Section V.
995 - Option F SelectPlan for Women – Inel/Stop/Disc: Age

To qualify for SelectPlan for Women (family planning services) under Medical Assistance you must meet certain criteria. You do not meet the criteria listed below.


Age 18 through 44.
Citation: PA Family Planning Waiver 12/29/05, Section III, 3.1
995 - Option G SelectPlan for Women – Inel/Stop/Disc: Insured

To qualify for SelectPlan for Women (family planning services) under Medical Assistance you must meet certain criteria. You do not meet the criteria listed below.


Be uninsured or have no family planning insurance coverage.
Citation: PA Family Planning Waiver 12/29/05, Section III, 3.1
995 - Option H SelectPlan for Women – Inel: Not Female

To qualify for SelectPlan for Women (family planning services) under Medical Assistance you must meet certain criteria. You do not meet the criteria listed below.


Be female.
Citation: PA Family Planning Waiver 12/29/05, Section III, 3.1
995 - Option J SelectPlan for Women – Inel/Stop/Disc: Pregnant

To qualify for SelectPlan for Women (family planning services) under Medical Assistance you must meet certain criteria. You do not meet the criteria listed below.


Not be pregnant.
Citation: PA Family Planning Waiver 12/29/05, Section III, 3.3
995 - Option K SelectPlan for Women – Inel/Stop/Disc: Sterilization

To qualify for SelectPlan for Women (family planning services) under Medical Assistance you must meet certain criteria. You do not meet the criteria listed below.


Have not had a treatment or procedure that prevents pregnancy.
Citation: PA Family Planning Waiver 12/29/05, Section III, 3.3
995 - Option L SelectPlan for Women – Inel/Stop/Disc: Not Citizen/Legal Alien

To qualify for SelectPlan for Women (family planning services) under Medical Assistance you must meet certain criteria. You do not meet the criteria listed below.


Be a U.S. citizen or have legal immigration status
Regulations and/or law: 8 USC 1611; 55 Pa. Code 150.1(b)(1)&(2), 42 CFR 435.406 & 435.407
995 - Option M SelectPlan for Women – Inel/Stop/Disc: Not PA Resident

To qualify for SelectPlan for Women (family planning services) under Medical Assistance you must meet certain criteria. You do not meet the criteria listed below.


Be a resident of Pennsylvania
Regulation and/or law: 55 Pa. Code 148.1 & 148.3
995 - Option N SelectPlan for Women – Inel/Stop/Disc: Identity Not Provided

To qualify for SelectPlan for Women (family planning services) under Medical Assistance you must meet certain criteria. You do not meet the criteria listed below.


Provide proof of identity
Regulations and/or law: 109-171 Deficit Reduction Act of 2005, Section 6036; 42 CFR 435.407


Verilənlər bazası müəlliflik hüququ ilə müdafiə olunur ©azrefs.org 2016
rəhbərliyinə müraciət

    Ana səhifə