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Plan First, is a Montana Medicaid Waiver that covers family planning services for eligible women.  Some of the services covered include office visits, contraceptive supplies, laboratory services, and testing and treatment of STDs. 

June 2014 Medicaid 1115 Plan First Family Planning Waiver Renewal Submission

General Eligibility Criteria

  • Montana Resident
  • Female 19 through 44
  • Able to bear children and not presently pregnant
  • Annual household income up to and including 211% Federal Poverty Level
  • Applicant cannot presently have any other family planning services coverage (self declared or claims identified)
2014 Federal Poverty Guidelines

Family Size

211% FPL

1 $25,207
2 $33,977
3 $42,746
4 $51,516
5 $60,286
6 $69,055
7 $77,825
8 $86,594
Acceptable Identity and Citizenship Documents

PRIMARY DOCUMENTATION OF CITIZENSHIP AND IDENTITY
Primary evidence of citizenship and identity is documentary evidence of the highest reliability. Obtain primary evidence of citizenship and identity before using secondary evidence. Applicants or recipients born outside the U.S. who were not citizens at birth must submit a primary document as evidence of citizenship.

PRIMARY DOCUMENTS --verifies both citizenship and identity

EXPLANATION

U.S. Passport

U.S. Passport does not have to be currently valid to be accepted, as long as it was originally issued without limitations. Do not accept any U.S. Passport as verification of citizenship if it was issued with limitations; it may, however, be used as proof of identity. Through 1980, spouses and children were sometimes included on one passport. Citizenship and identity of all included persons can be established.

Certificate of Naturalization (Form N-550 or N-570)

Issued by Department of Homeland Security (via USCIS)

Certificate of Citizenship (Form N-560 or N-561)

Issued by Department of Homeland Security (via USCIS) for individuals who derive citizenship through a parent

* Tribal Documents

Issued by federally recognized Indian Tribe evidencing membership, enrollment in, or affiliation with such Tribe. Document must identify the federally recognized Indian Tribe that issued it, identify the individual by name and confirm the individual’s membership, enrollment in or affiliation with the Tribe.
Examples include, but are not limited to: enrollment/membership card, certificate of degree of Indian blood issued by BIA, Tribal census document or document issued by the Tribe indicating the individual’s affiliation with the Tribe.

SECONDARY DOCUMENTATION OF CITIZENSHIP ONLY
Secondary documents can be used when primary evidence of citizenship is not available. Applicants or recipients born outside the U.S. must submit a primary document as evidence of citizenship. Additional documentation is required to prove identity.

SECONDARY DOCUMENTS -- verifies citizenship only

EXPLANATION

A U.S. public birth record showing birth in: * Any of the 50 U.S. States * District of Columbia * American Samoa * Swain's Island * Puerto Rico (if born on or after January 13, 1941) * Virgin Islands (if born on or after January 17, 1917) * Northern Mariana Islands (if born after November 4, 1986) * Guam (if born on or after April 10, 1899)

The document must be issued by the State, territory or local jurisdiction and have been issued before the person turned five years old. If the birth record document was amended after the individual was age five, it is considered fourth level evidence of citizenship. y

Certification of Report of Birth Abroad (Form DS-1350)

Issued by Department of State (Washington D.C.) to citizens born outside the U.S. who acquired citizenship at birth

Consular Report of Birth Abroad of a Citizen of the United States of American (Form FS-240)

Issued by Department of State consular office. Children born outside the U.S. to U.S. military personnel usually have this documentation.

Certification of Birth Abroad (Form FS-545)

Issued by Department of State consulate prior to November 1, 1990.

United States Citizen Identification Card (I-197) or prior version (I-179)

The former INS issued I-179 from 1960 until 1973. I-197 issued from 1973 until April 7, 1983. Neither form is currently issued, but both are still valid evidence of citizenship.

American Indian Card (I-872)

Must be issued by Department of Homeland Security and have classification of ‘KIC” – Texas Band of Kickapoo’s living near the U.S./Mexican boarder

Northern Mariana Card (I-873)

The former INS issued I-873 to collectively naturalized U.S. citizens born in the Northern Mariana Islands before November 4, 1986. The card is no longer issued, but is still valid evidence of citizenship.

Final Adoption Decree

Decree must show the child's name and a U.S. place of birth. If adoption is not finalized and child's birth state will not release a birth certificate prior to final adoption, a statement from a state approved adoption agency that shows the child's name and U.S. place of birth is acceptable. Adoption agency must state that the source of birth place information is from the child's original birth certificate.

Evidence of U.S. Government Civil Service Employment

Must show employment by the U.S. government prior to June 1, 1976.

Official Military Record of Service

Document must show a U.S. place of birth. Can use a DD-214 or similar official document showing a U.S. place of birth.

Child. Citizenship Act of 2000

Evidence of meeting automatic criteria of U.S. citizenship as outlined in this Act.

THIRD LEVEL DOCUMENTATION OF CITIZENSHIP ONLY
Third level documents can be used when primary or secondary evidence of citizenship is not available. Additional documentation is required to prove identity. Third level evidence is generally a non-government document showing a U.S. place of birth. The place of birth on the non-government document and the application must agree.

THIRD LEVEL DOCUMENTS -- verifies citizenship only

EXPLANATION

Extract of hospital record on hospital letterhead.

Must be established at time of person's birth and be created at least five years before initial application date and indicate a U.S. place of birth. For children under age 16, the document must have been created near the time of birth OR five years before the application. DO NOT ACCEPT SOUVENIR BIRTH CERTIFICATE ISSUED BY THE HOSPITAL. All hospital-issued birth certificates are considered to be souvenirs.

Life, health or other insurance record

Must show a U.S. place of birth and have been created at least five years before the initial application date.

Religious Records

Must be recorded in the U.S. within three months of birth and show a U.S. place of birth. Must show either the date or individual’s age at the time the record was made. The record must be ‘official’ and recorded with the religious organization. (Entries in a family bible are NOT considered religious records)

Early School Records

Must show a U.S. place of birth. The record must also show the child’s name, date of admission to the school, date of birth, and the name(s) and place(s) of birth of the child’s parents.

NewPlan First Member Notices

How to Apply:

The easiest way is to Apply Online.

For more information:
Plan First Brochure
1-855-854-1399 In-State Toll Free
1-406-444-6446 Out-of- State and Helena Area
Email:  planfirst@mt.gov