Medicaid – documents required for apply and coverage limitation

COVERAGE AND LIMITATIONS:

Frequency is limited to once in a lifetime.

BRCA1/BRCA2 gene analysis is covered for individuals meeting the following criteria:

1. For individuals without diagnosis of breast or ovarian cancer:
   a. Two first-degree relatives with breast cancer, one of whom was diagnosed at age 50 years or younger;
   b. A combination of three or more first- or second-degree relatives with breast cancer regardless of age at diagnosis;
   c. A combination of both breast and ovarian cancer among first- or second-degree relatives;
   d. A first-degree with bilateral breast cancer;
   e. A combination of two or more first- or second-degree relatives with ovarian cancer, regardless of age at diagnosis;
   f. A first or second-degree relative with both breast and ovarian cancer at any age;
   g. History of breast cancer in a male relative; or
   h. For women of Ashkenazi Jewish descent, any first-degree relative (or two second-degree relatives on the same side of the family) with breast or ovarian cancer.
2. A family history of breast or ovarian cancer that includes a relative with a known deleterious BRCA mutation; or
3. A personal history of breast cancer plus one or more of the following:
   a. Diagnosed at age ≤ 45 years;
   b. Diagnosed at age ≤ 50 years with ≥ 1 close blood relative with breast cancer diagnosed at any age or with a limited family history;
   c. Two breast primaries when first breast cancer occurred at age ≤ 50 years;
   d. Diagnosed at age ≤ 60 years with a triple negative breast cancer;
   e. Diagnosed at age ≤ 50 years with a limited family history;
   f. Diagnosed at any age, with ≥ 1 close blood relative with breast cancer diagnosed ≤ 50 years;
   g. Diagnosed at any age with ≥ 2 close blood relatives with breast cancer at any age;
   h. Diagnosed at any age with ≥ 1 close blood relative with epithelial ovarian cancer;
   i. Diagnosed at any age with ≥ 2 close blood relatives with pancreatic cancer or aggressive prostate cancer (Gleason Score ≥ 7) at any age;
   j. Close male blood relative with breast cancer; or
   k. For an individual of ethnicity associated with higher mutation frequency (e.g. Ashkenazi Jewish) no additional family history may be required.
4. Personal history of epithelial ovarian cancer; or
5. Personal history of male breast cancer; or
6. Personal history of pancreatic cancer or aggressive prostate cancer (Gleason Score ≥ 7) at any age with ≥ 2 close blood relatives with breast and/or ovarian and/or pancreatic cancer or aggressive prostate cancer (Gleason Score ≥ 7) at any age.

Required Information and Documentation

When applying for Medicaid, you must attest to being a West Virginia resident and a United States citizen or a legal alien. Non-U.S. citizens will be asked for an immigration document and ID number.

Examples of an immigration document include:

• Permanent Resident Card, “Green Card” (I-551);
• Reentry Permit (I-327);
• Refugee Travel Document (I-571);
• Employment Authorization Card (I-766);
• Machine Readable Immigrant Visa (with
  temporary I-551 language);
• Arrival/Departure Record (I-94/I-94A);
• Arrival/Departure Record in Foreign Passport (I-94);
• Foreign Passport;
• Certificate of Eligibility for Nonimmigrant Student Status (I-20);
• Certificate of Eligibility for Exchange Visitor Status (DS2019);
• Certification from U.S. Department of Health and Human Services (HHS) Office of Refugee Resettlement (ORR); and
• Alien Number (also called alien registration number or USCIS number) or 1-94 Number.

If you need assistance establishing your immigration status, contact your county DHHR office. All applicants must be given a reasonable opportunity to provide documents to establish U.S. citizenship or immigration status, unless we can verify this information electronically.

All applicants will need to provide the following information:

• Social Security Numbers (or document numbers for any legal immigrants who need insurance);
• Employer and income information for everyone in your family (for example, from paystubs, W-2 forms or wage and tax statements);
• The number of people you will claim as a dependent on your tax return, or if you will be claimed as a dependent by someone else on their tax return;
• Policy numbers for any current health insurance; and
• Information about any job-related health insurance available to your family.

The information you provide will be used to determine if you qualify for Medicaid and the coverage type. DHHR will also check your answers using information already in its databases and
databases from the Internal Revenue Service (IRS), Social Security, the Department of Homeland Security, and/or a consumer reporting agency. If the information does not match, you may be asked to
provide proof that your answers are correct. All information provided to DHHR will be kept confidential and secure, as required by law.