When a qualified provider says that a pregnant woman is presumptively eligible, the provider must send two copies of the MA 332 and a completed MA application form to the CAO. 55 Pa. Code § 140.141
The CAO must approve presumptive Healthy Beginnings within three work days after it gets the MA 332 and the application. The qualified provider must let the woman know in writing whether she is eligible or ineligible for presumptive Healthy Beginnings. 55 Pa. Code § 140.142 55 Pa. Code § 140.143
The individual cannot appeal the decision of the qualified provider. 55 Pa. Code § 140.144
The CAO must decide on the individual's eligibility for continuing MA benefits within 45 days of the date the qualified provider signed the MA 332. (See Section 318.9, Approving Healthy Beginnings.) 55 Pa. Code § 140.142
The CAO must not process any overpayment for medical services received during the period of presumptive eligibility. 55 Pa. Code § 140.146
When processing a presumptive eligibility application, the CAO must take the following actions:
1. Stamp the date on the MA 332 and the MA application form immediately after getting them.
2. Make sure the forms are complete. The MA 332 must be completed, signed, and dated by the qualified provider and the applicant. The MA application form must show the individual’s name and address, and it must be signed by the individual.
NOTE: If the information is incomplete, return the packet promptly to the qualified provider and ask for the missing information.
3. Enter the information into the Client Information System (CIS). Complete any extra file clearance that is needed. Include provider information from the MA 322 in CIS or e-CIS.
4. If the information is complete, approve presumptive eligibility using category PS with program status code 17. Complete the approval within three work days from the date the forms were received. The open date is the date the qualified provider signs the MA 332. The PS 17 individual is not enrolled in a managed care plan, such as an HMO or in HIPP.
5. CIS enters a future close date 45 days from the open date.
6. Give the presumptively eligible applicant information and the forms needed for ongoing Healthy Beginnings eligibility.
7. Decide on eligibility for ongoing benefits no later than the 45th day after the open date of presumptive eligibility. Decide whether there is a need for retroactive MA.
NOTE: Do not delay a decision on continuing Healthy Beginnings while waiting for more verification for other assistance programs. Retroactive benefits may not be approved for a Healthy Beginnings presumptively eligible pregnant woman.
8. If the applicant is eligible for continuing MA, send a notice to the applicant. Complete part C of the MA 332, and send a copy to the qualified provider.
NOTE: If the applicant was authorized as presumptively eligible and there were no other medical expenses, open continuing MA by updating the information in CIS. If CIS does not allow an update due to the future 45 day close date, then complete a MA opening through the application process. If the applicant had other medical expenses not covered under presumptive eligibility, then approve retroactive MA to cover the medical expenses.
9. If the applicant is not eligible for continuing MA, then:
Close the presumptive eligibility and send an Advance Notice to the individual and the provider letting her know that her benefits will be discontinued.
Send a notice to the applicant explaining why he or she is not eligible and telling the last date of presumptive eligibility coverage.
10. If the child is born during the 45 day presumptive eligibility period, the newborn is not automatically eligible for MA for one year. Do not approve MA for the newborn using the Newborn Eligibility Form (MA 112). The newborn is eligible if the mother is determined to be eligible for MA based on the MA application form. If that is the case, the CAO must approve the newborn in a separate PS budget group with program status code 16 and open the budget with the newborn's date of birth as the start date.
Updated February 14, 2012, Replacing October 13, 2009