MEDICAID FAMILY PLANNING WAIVER (FPW)



FPW is a program that provides family planning services to both men and women. To qualify for Medicaid Family Planning Waiver (FPW), an applicant must meet basic eligibility requirements such as, but not limited to:

• not be eligible for or receiving coverage in another Medicaid aid program/category

• be a U.S. citizen or qualifying alien * be a resident of North Carolina

• meet income criteria * not be pregnant or sterile

• meet age requirements: women (19 – 55) and men (19 – 60)

This program provides very limited family planning services and is not a comprehensive health insurance plan. You may inform the agency of your interest in this program by completing the questionnaire below or by answering a few questions on your application/review paperwork. Your Medicaid worker will evaluate eligibility for other Medicaid coverage prior to evaluating eligibility for FPW coverage.

You indicated on the Medicaid application that you want to apply for family planning services. To be eligible for Medicaid Family Planning Waiver services you must be a woman age 19 through 55 or a man age 19 through 60 and have not had a medical procedure that would prevent you from having a baby or fathering a baby.

Do you still wish to apply for Medicaid Family Planning Waiver? YES NO

If YES:

Name of FPW applicant: __________________________________________

Social Security Number: __________________________________________

Are you pregnant? YES NO

Have you been sterilized? YES NO

Do you want to apply for Medicaid Family Planning Waiver for your spouse/significant other? YES NO

If YES:

Name of Spouse/Significant Other: __________________________________

Social Security Number: __________________________________________

Are they pregnant? YES NO

Have they been sterilized? YES NO

This information is needed to complete eligibility for Medicaid Family Planning Waiver.

If you are found to be ineligible for full Medicaid, but eligible for FPW, the FPW Medicaid is authorized for 12 months. You are “locked in” to this 12-month period. If you later reapply for full Medicaid during this 12-month period, your eligibility will be determined based on this certification period. Medicaid may or may not be authorized based on these requests.

Medicare recipients are ineligible for Medicaid Family Planning Waiver services.

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