Medicaid for Breast and Cervical Cancer

Medicaid for Breast and Cervical Cancer (MBCC) Information

Low-income, uninsured women diagnosed with breast or cervical cancer who are in need of treatment may qualify for medical assistance through Medicaid for Breast and Cervical Cancer (MBCC). The Texas Department of State Health Services (DSHS) Breast and Cervical Cancer Services (BCCS) program determines eligibility criteria for MBCC.


Texas Breast and Cervical Cancer MBCC Facts

MEDICAID FOR BREAST AND CERVICAL CANCER

Medicaid for Breast and Cervical Cancer (MBCC) is a special Medicaid program authorized by federal and state laws to provide access to cancer treatment services for qualified, low-income women. Agencies that contract with the Texas Department of State Health Services for the delivery of breast and cervical cancer screening and diagnostic services are responsible for assisting women with the MBCC application, determining presumptive eligibility and assessing case management needs.
A health care provider must evaluate whether a woman meets the eligibility criteria described below before offering this resource. If she meets the eligibility criteria, she should be referred to a Breast and Cervical Cancer Services (BCCS) contractor to apply for MBCC. To locate the nearest BCCS contractor, go to: www.dshs.state.tx.us/bcccs/locator.shtm.

Medicaid for Breast and Cervical Cancer (MBCC) FAQ

ELIGIBILITY

To be eligible for MBCC, a woman must be:

  • Diagnosed and in need of treatment for one of the following biopsy-confirmed definitive breast or cervical diagnoses: CIN III, severe cervical dysplasia, cervical carcinoma in-situ, invasive cervical cancer, ductal carcinoma in situ or invasive breast cancer, as defined by BCCS policy; and
  • Have income at or below 200% of the Federal Poverty Income Guidelines, as defined by BCCS policy; and (see Table at: www.dshs.state.tx.us/bcccs/eligibility.shtm#income.)
  • Uninsured, that is, she must not otherwise have creditable coverage (including current enrollment in Medicaid); and
  • Under age 65; and
  • A Texas resident; and
  • A U.S. citizen or qualified alien.

REFERRALS

  • To ensure a successful referral and to facilitate prompt enrollment of qualified women into MBCC, health
  • care providers must:
  • Identify the appropriate BCCS contractor;
  • Ensure that the diagnosis falls within the qualifying timeframe;
  • Ensure the pathology report has a definitive qualifying diagnosis (all diagnoses must be biopsyconfirmed);
  • Use the “Medicaid for Breast and Cervical Cancer: Guidelines for Determination of Qualifying
  • Diagnosis” as a reference tool
  • (http://www.dshs.state.tx.us/chscontracts/pdf/MBCCQualifyingDx072008.pdf);
  • Provide the client with a copy of the pathology report for the referral BCCS contractor; or
  • Fax the pathology report to the referral BCCS contractor, to the Attention of the agency’s Case
  • Manager; and
  • Most importantly, communicate with the referral BCCS contractor about the necessary
  • documents the client will need to bring to complete the eligibility and application process
  • (financial documents, citizenship or alien status).

Federal Legislation
On October 24, 2000, the Breast and Cervical Cancer Prevention and Treatment Act of 2000 was signed into law. This Act gives states the option to provide Medicaid medical assistance to women who were screened through the Centers for Disease Control and Prevention’s (CDC) Breast and Cervical Cancer Early Detection Program (NBCCEDP) and found to have breast or cervical cancer.

In January 2007, Congress reauthorized NBCCEDP to provide women with low-cost screening and diagnostic services for breast and cervical cancer.
State Legislation
In 2002, Texas began providing Medicaid to women who are diagnosed with breast or cervical cancer by a DSHS BCCS program contractor. Most recently, the 80th Texas Legislature passed Senate Bill 10 that allows any health care provider to refer eligible women in need of treatment for breast or cervical cancer to Medicaid.

Beginning September 1, 2007, any woman diagnosed with breast or cervical cancer who meets all eligibility requirements, as determined by DSHS BCCS policy for Medicaid for Breast and Cervical Cancer, may receive services.

Enrollment

  • Contact a BCCS contractor in your area, visit the BCCS Clinic Locator.
  • A BCCS contractor will screen for eligibility and if applicable complete the Medicaid Medical Assistance Application (form 1034). The BCCS contractor will review and collect required documentation of eligibility.
  • DSHS will verify the patient’s qualifying diagnosis and send Form 1034 to HHSC.
  • HHSC Centralized Benefits Services makes the final Medicaid eligibility determination.

Coverage

  • A woman is entitled to full Medicaid coverage beginning on the day after the date of diagnosis (services are not limited to the treatment of breast and cervical cancer).
  • Medicaid eligibility continues as long as the Medicaid Treatment provider certifies that the woman requires active treatment for breast or cervical cancer.
  • Should a woman have a recurrent breast or cervical cancer, the BCCS contractor must reapply for the woman to be eligible for Medicaid.

Contact Information

  • For the location of a BCCS contractor in your area, call 2-1-1 or visit the BCCS Clinic Locator.
  • Contact the Health and Human Services Commission by dialing 2-1-1 concerning questions and or information regarding Medicaid eligibility and enrollment.
  • Additional information may be obtained through the Centers for Medicare and Medicaid Services (CMS) at: www.cms.gov .

Guidelines for Determination of Qualifying Diagnosis

The Department of State Health Services is providing the following guidance to healthcare providers and Breast and Cervical Cancer Services (BCCS) contractors to facilitate their determination of qualifying diagnoses for Medicaid for Breast and Cervical Cancer (MBCC). Analysis of all biopsies must be performed by a US CLIA certified laboratory.

Cervical Cancer Qualifying Diagnosis

Qualifying pre-cancerous cervical diagnoses are biopsy-confirmed*:

  • CIN III
  • Severe dysplasia
  • Carcinoma or adenocarcinoma in situ

Qualifying malignancies of the cervix are biopsy-confirmed*:

  • ◄Squamous cell carcinoma
  • ◄Adenocarcinoma
  • ◄Invasive endocervical adenocarcinoma
  • ◄Small cell carcinoma
  • ◄Invasive cervical cancer
  • ◄Invasive neoplasm
  • ◄Malignant neoplasia
  • ◄Melanoma
  • ◄Sarcoma
  • ◄Glassy cell carcinoma
  • ◄Adenoid cystic carcinoma
  • ◄Adenosquamous carcinoma

*Cervical biopsy or endocervical sampling of CIN III, severe dysplasia, carcinoma or adenocarcinoma in situ, or cervical malignancy qualifies as “biopsy confirmed”.
Breast Cancer Qualifying Diagnosis
A qualifying pre-cancerous breast diagnoses* is biopsy-confirmed:
◄Ductal carcinoma in situ (DCIS)

Qualifying breast cancer diagnoses must be biopsy-confirmed.  On the pathology report, the diagnosis and/or the specimen description must include at least one of the following phrases: “breast cancer”, “breast carcinoma”, or “breast malignancy”
Examples of the majority of breast cancer types:
1. Ductal Carcinomas:

  • ◄Invasive
  • ◄Comedo
  • ◄Inflammatory
  • ◄Medullary
  • ◄Mucinous (colloid)
  • ◄Papillary or Micropapillary
  • ◄Scirrhous
  • ◄Tubular
  • ◄Cribiform

2. Lobular Carcinoma:

  • ◄Invasive

3. Nipple Carcinoma:

  • ◄Paget’s disease

4. Other Carcinomas:

  • ◄Carcinoma, NOS (not otherwise specified)
  • ◄Undifferentiated carcinoma
  • ◄Phyllodes malignant tumor
  • ◄Sarcoma
  • ◄Primary lymphoma
  • ◄Secretory
  • ◄Apocrine
  • ◄Metaplastic
  • ◄Carcinoma with endocrine differentiation
  • ◄Adenoid cystic carcinoma

Breast and Cervical Cancers

For primary cancers, terms such as “compatible with” and “consistent with” do not qualify as definitive diagnoses. If the pathologist is certain the finding is breast or cervical cancer as described above, then it must be clearly stated in the final pathology report.
For metastatic or recurrent cancers, an unequivocal diagnosis of malignancy is required. However, since many metastatic or recurrent cancers may look the same, the primary does not need to be explicitly diagnosed. Terms such as “compatible with” and “consistent with” a breast or cervical cancer are acceptable. For example, a diagnosis such as “metastatic adenocarcinoma consistent with the prior breast primary” would be acceptable.
* The diagnosis of lobular carcinoma in situ (LCIS) is not considered a qualifying precancerous or breast cancer diagnosis for referral to MBCC.