There are two types of Presumptive Eligibility (PE):
Traditional PE for pregnant women (See Section 312.91)
Hospital-based PE (See Section 312.92)
Qualified hospital PE providers and qualified MA providers for pregnant women are responsible for determining eligibility for PE. The PE provider makes the PE determination based on the following criteria:
Categorical eligibility.
Citizenship.
State residency.
Identity.
Income based on tax household size.
[42 CFR §435.116(c)] [42 CFR §435.1103] [42 CFR §435.1110]
The PE category income limits are:
1. Pregnant women and children under age 1 – 215% of the FPIG.
2. Children ages 1-5: 157% of the FPIG.
3. Children ages 6-18: 133% of the FPIG.
4. Parents/caretakers: 33% of the FPIG.
5. Former foster care children under age 26 - no income test
The PE provider may determine PE based on self-attested information. The PE provider may provide documentation with the application. The PE providers are encouraged to assist the individual in completing the MA application.
PE eligibility begins the date the PE determination is made.
The end date of the PE period is whichever date comes earlier:
the last day of the month following the month of the PE begin date; or
the date ongoing MA eligibility is determined.
NOTE: If a PE recipient is determined ineligible for ongoing MA, PE must be discontinued at the time the ongoing MA determination is made.
NOTE: If a child is born during the PE period, the newborn is not automatically eligible for MA for one year. The newborn is eligible only if the mother is determined to be eligible for ongoing MA. If the mother is determined eligible and authorized for ongoing MA, the CAO must authorize MA for the baby with the newborn’s date of birth as the start date.
Limits on PE periods:
Pregnant women, only one PE period may be authorized per pregnancy.
Children, parents/caretakers and former foster care children under age 26, PE periods are limited to one per 12-month period.
Example: A woman is authorized MG17 (as a parent/caretaker) for the period 2/5/14-3/31/14 based on a PE application. No ongoing MA determination is made. A second PE application for the woman is received 7/5/14. The woman is not eligible for PE as she has already received PE during the past 12 months.
Healthcare Benefits Packages:
Parents/caretakers and former foster care individuals will receive Healthcare Benefits Package HCBP 02. Children under age 21 will receive HCBP 01.
Pregnant women who are eligible for PE will receive HCBP 06.
NOTE: All PE recipients are enrolled in Fee for Service MA.
Qualified MA providers that provide pregnancy related services are allowed to make PE determinations for pregnant women. MA providers for pregnant women include outpatient hospital clinics, independent clinics, federally qualified health centers, rural health centers, physician practices, certified registered nurse practitioners, midwives and birth centers. Providers who determine PE for pregnant women use the MA 332 form to make the eligibility determination.
The MA 332 form is submitted to the CAO. The PA 600HC application should be submitted with the MA 332 if the applicant chooses to apply for ongoing MA. The provider should encourage the applicant to apply for ongoing MA to ensure the pregnant woman has MA throughout her pregnancy and post- partum period.
PE for pregnant women providers must:
Complete Part A and Part B of the MA 332
Submit two copies of the MA 332
Assist the applicant in completing and submitting the PA 600HC if the applicant chooses to apply for ongoing MA
The MA 332 must be submitted to the CAO within five business days of the date PE was determined. This may be done by mail or fax; or the applicant may hand-carry the completed forms to their CAO. PE providers for pregnant women use MAGI rules to determine eligibility for PE.
NOTE: The PE provider must inform the applicant of eligibility or ineligibility for PE and give the applicant a copy of the MA 332.
The CAO must:
Date stamp the MA 332 and PA 600HC immediately after getting them
Make sure MA 332 is completed, signed and dated by the qualified provider and applicant.
Review the MA application (PA 600HC) and make sure it has the applicant’s name, address and signature.
NOTE: If the information is incomplete, return the packet promptly to the qualified provider and ask for the missing information.
The ACA allows qualified and enrolled MA hospital providers to make PE determinations for individuals in MAGI categories.
The MAGI groups that qualify for hospital-based PE are:
Pregnant women.
Children age 18 and younger.
Parents /caretakers.
Former foster care children under age 26 who have aged out of foster care.
[42 CFR 435.1102] [42 CFR §435.1103]
The MA enrolled hospital PE providers submit PE applications online through COMPASS. The hospital PE provider can submit PE applications for individuals in any of the defined PE groups. The PE application also functions as the ongoing MA application.
NOTE: If there is more than one individual in the family requiring PE services, the hospital PE provider may apply for PE for all individuals in the tax household who require PE services, if they are otherwise eligible.
The hospital PE provider must:
Determine eligibility for PE for an individual by completing the PE Worksheet for each applicant.
Submit the PE application through COMPASS as an MA provider. The PE application must be submitted within five business days of the PE determination.
Enter the PE begin date in the “Date of First Admission Treatment”.
Answer the PE question on the COMPASS application “Yes”.
Scan and attach the PE Worksheet and any verification through the scan feature in COMPASS or fax it to the CAO.
E-sign the application.
NOTE: The PE provider must inform the applicant of eligibility or ineligibility for PE and give the applicant a copy of the PE Worksheet.
The CAO authorizes PE using the following categories/program status codes:
PS 17 - pregnant women
MG 17 - parents/caretakers, children or former foster care children.
If a pregnant woman also qualifies for PE in one of the other PE groups, then the pregnant woman must be authorized in the MG 17 category/program status code.
Example: A pregnant woman’s tax household has a net income under 33 percent of the FPIG. She is also the parent of a six year old child. The CAO authorizes PE in the MG 17 category/PSC.
Example : A pregnant woman’s tax household has a net income that is greater than 33% of FPL but less than 215% of FPL. The CAO receives a PE application for the pregnant woman who is also the parent of a three year old child. The CAO authorizes PS17 for the pregnant woman.
Processing a PE application:
1. Identify a PE COMPASS application.
PE indicator will be “Yes” on COMPASS summary page.
“Provider PE Application” will be indicated on the CAPINF screen in AP in the Application Type field
2. Assign application for expediting processing. PE applications must be processed within 5 business days from date of submission.
3. Review eCIS to determine if prior PE periods were authorized for the applicant. If the applicant is not eligible because of a prior PE period:
a. Send a Notice of Ineligibility for PE.
b. Use rejection notice/option code 981/E for pregnant women.
c. Use rejection notice/option code 986/J for MG17.
d. Determine eligibility for ongoing MA.
4. Enter the PE begin date on the Program Request screen. The system will determine the correct PE period based on the PE begin date. The caseworker must not enter a PE close date on the Program Request screen when processing PE.
5. Pend ongoing MA on the “Program Request Screen”
6 Process the PE budget:
a. Select MG17 from the dropdown menu on the “Program Request Questions” screen, for parent/caretakers, children, and former foster children under age 26.
b. Complete the “Pregnancy Screen” for pregnant women. For PS17, select “Yes” next to the Presumptive Eligibility question.
c. If a pregnant woman qualifies in one of the MG17 categories, process as MG17.
d. Process PE with the information provided on the application.
NOTE: If all required information has been provided with the application, or the caseworker verifies required information electronically, ongoing MA can be processed without a PE period.
7. Scan and attach the PE Worksheet or MA 332 to the case record.
8. Send a Notice of Eligibility for PE to the individual and the PE provider.
NOTE: There is no retroactive MA with PE. When ongoing MA is processed, retroactive MA can be processed if requested.
9. Inform the individual of any required verification needed to determine ongoing MA eligibility.
10. Determine ongoing MA eligibility within five working days of receiving verification, no later than the end of the PE period. If a PE recipient is determined ineligible for ongoing MA, do not process an overpayment for the PE period.
11. Issue a Notice of Eligibility or Ineligibility for ongoing MA to the individual.
Issued September 19, 2014