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Summary. CAWEM is a benefit package that covers emergency medical services only. In an APD context, an applicant must meet all of the OSIPM eligibility factors except the citizen/alien status and SSN requirements. The CAWEM benefit package also exists for MAGI and applicants should be referred for MAGI first. In most circumstances, the only time APD would carry a CAWEM case would be for individuals aged 65 or over.
Eligibility Requirements. To qualify for the CAWEM benefit package, a person must meet all the financial and nonfinancial eligibility requirements of another medical assistance program, except the citizen/alien status and Social Security Number (enumeration) requirements. Applicants who undocumented (do not have a legal immigration status) are not required to provide proof of their citizenship or alien status.
Exception. There is no CAWEM eligibility in the QMB-BAS, QMB-SMB, or QMB-SMF programs.
What is Covered. The CAWEM benefit package covers emergency medical services only. This means the client requires immediate medical treatment due to the sudden onset of a medical condition, and the absence of medical treatment could reasonably be expected to result in any of the following:
Tests to diagnose the patient's performed after the date of request may be covered. Separate charges for post-operative visits and procedures outside the dates of the emergency treatment are not covered.
Important: 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 pursuant to the OHA administrative rules.
Individuals may 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 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.
Most clients will apply under the MAGI programs and use the OHP 7210 application or apply online through healthcare.gov. Individuals who do not want to use the healthcare.gov website can call the OHP central number (1-800-359-9517), request an application, complete it, and return it to the Oregon Health Authority (branch 5503).
Clients who are 65 years of age or older can apply under OSIPM-OAA. They must complete the SDS 539A. A client under age 65 applying under OSIPM-AD or OSIPM-AB would have to meet SSA disability criteria (PMDDT decision). There are some instances when a person who is a non-citizen can be CAWEM eligible if they meet the requirements of the OSIPM-EPD program.
CAWEM Prenatal. Pregnant CAWEM clients may be eligible for expanded benefits. The CAWEM prenatal program uses case descriptors “CWM” and “CWX” and need/resource code “CWX” with the due date. The CAWEM Plus medical benefits package is a slightly reduced version of the OHP Plus benefit package and will provide prenatal Medicaid serviced to pregnant CAWEM women. Services that are not covered:
For more information on the CAWEM prenatal program, please see SS-IM-11-042 and DMAP IM 13-069. |
Coding and Notices. 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 for CAWEM program. Click here to open a PowerPoint containing additional coding help.
Note: No denial notice for OSIPM is required when approving OSIPM-CAWEM as the applicant is eligible for a medical benefit.
Claims Payment. Providers submit claims in the same manner as they do for other Medicaid programs. Only claims for emergency services can be paid (except for CWX). DMAP plans follow-up claims reviews to identify and correct providers' misunderstandings of the state's definition for emergency services.
