There are two types of Presumptive Eligibility (PE):
Traditional PE for pregnant women (See Section 312.81)
Hospital-based PE (See Section 312.82)
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.
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. Individuals age 19-64: 133% of the FPIG.
6. Former foster care children under age 26 - no income test
The PE provider may determine PE based on self-attested information. The PE provider must inform the PE applicant of the choice to apply for ongoing MA or not. The PE provider may encourage the PE applicant to apply for MA and assist the individual in completing the MA application. The PE provider may provide documentation with the 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, and individuals age 19-64. 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, individuals age 19-64, and former foster care individuals 21 and older will receive the Adult Healthcare Benefits Package.
Children under age 21 will receive the Children's Healthcare Benefits Package.
Pregnant women who are eligible for PS 17 will receive PE for Pregnant Women Healthcare Benefits Package.
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 PE applicant may choose whether to apply for ongoing MA or not. 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
Determine eligibility for PE
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, if a PA 600HC is submitted with the MA 332
NOTE: If the information is incomplete, return the packet promptly to the qualified provider and ask for the missing information.
Process and authorize the PE period within five working days of receiving the MA 332.
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.
Individuals age 19-64.
Former foster care children under age 26.
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.
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. Additional PE applicants in the same household can be added to the PE Worksheet.
Select to apply for PE only, PE/ongoing MA or MA only, based on the applicant's choice and eligibility.
NOTE: If applying for PE only, the provider completes a shorter, simplified PE only application.
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”.
Scan and attach any verification through the scan feature in COMPASS, mail 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.
All COMPASS hospital PE applications, including PE only and PE/ongoing MA, are evaluated through Real-Time Eligibility (RTE). PE only applications may be authorized through RTE for a PE Period. PE/ongoing MA applications are evaluated through RTE for ongoing MA. Ongoing MA may be authorized through RTE. If ongoing MA cannot be authorized for a PE/ongoing MA application, the application will be evaluated for auto-AP. The caseworker must manually process the PE period and determine ongoing MA eligibility.
The CAO authorizes PE using the following categories/program status codes:
PS 17 - pregnant women
MG 17 - parents/caretakers, children, individuals age 19-64, or former foster care children.
If a hospital provider submits an application for a pregnant woman who 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 of less than133% of the FPIG. She has no other dependent children. The CAO authorizes PE in MG 17 category/PSC.
Example : A pregnant woman’s tax household has a net income that is greater than 133% of FPIG but less than 215% of FPIG. 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.
If a PE provider of pregnancy services submits an application for a pregnant woman, PS17 must be authorized.
Example: A pregnant woman seeks services from a Nurse-Midwife, who is a qualified PE provider of pregnancy services. The qualified PE provider of pregnancy services determines eligibility and submits a PE application. The CAO authorizes PE in the PS 17 category/PSC.
If a parent/caretaker has income above 33% of the FPIG, the individual may qualify for PE as an individual age 19-64.
Example: A parent of two children applies for PE. The parent has income over 33% of the FPIG but under 133% of the FPIG. The parent is eligible for PE as an individual age 19-64. The CAO authorizes PE in the MG 17 category.
Processing a PE application:
1. Identify a PE COMPASS application.
"Presumptive Eligibility" will be indicated in the benefits field on the CAPWAD screen in AP.
“Provider PE Application” will be indicated on the CAPINF screen in AP in the Application Type field
2. Assign the application for expediting processing. PE applications must be processed within five business days from date of submission.
3. If the applicant is not eligible because of a prior PE period:
a. Send a Notice of Ineligibility for PE. An override must be performed in order to reject PE. A manual notice must be issued.
b. 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,
individuals ages 19-64,
former foster children under age 26,
pregnant women who qualify in one of the other PE categories.
b. Complete the “Pregnancy Screen” for pregnant women. For PS17, select “Yes” next to the Presumptive Eligibility question. Process a PE Budget as PS17 if:
The PE application is from a qualified provider of pregnancy services, or
The PE application is from a hospital PE provider for a pregnant woman whose income is between 133% and 215% of the FPIG, and does not qualify for PE in any of the other PE categories.
c. 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, and the individual is eligible, ongoing MA can be processed without a PE period. Automated data sources may be used for ongoing MA only, but never for the PE period.
7. Scan and attach the MA 332 and PA600HC from the PE for pregnant women provider to the case record. COMPASS PE Worksheets and applications are automatically scanned into Imaging when applications are submitted by qualified PE hospital providers. If the PE Worksheet and/or Application is not available in Imaging, go to AP, enter the case record number in “By App Details” and then go to the CAPWAD screen. The PE Worksheet and application can be viewed and printed from the CAPWAD screen.
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.
For COMPASS PE/ongoing MA applications, the effective begin date for ongoing MA must be the date in the Date of First Admission or Treatment field on the COMPASS Summary Page.
For PA600HC applications submitted with the MA332, the effective begin date for ongoing MA is the earliest signature date on the application.
11. If a PE recipient is determined ineligible for ongoing MA, do not process an overpayment for the PE period.
12. When reviewing for ongoing MA, the worker must also review for retroactive MA if it was requested on the application.
NOTE: if an individual who has initially applied for PE only submits an ongoing MA application at any time during the PE period, the PE period may be extended to allow sufficient time for ongoing MA eligibility to be determined. A second PE period may be added beginning the day after the first PE end date. All ongoing MA applications must be processed timely. The PE period must close when ongoing MA eligibility is determined.
13. Issue a Notice of Eligibility or Ineligibility for ongoing MA to the individual.
312.84 When a PE Period Does Not Need to Be Authorized
A PE period must be authorized, if determined eligible by a qualified PE provider, unless one of the following conditions apply:
The individual applying for PE has been authorized in a PE budget within the past 12 months or within the same pregnancy.
Example: A PE provider of pregnancy services submits an MA 332 PE-only application on August 12 for Mary, who is pregnant. The caseworker reviews and sees that Mary was authorized for PE in February of the same year. Mary is not eligible for a second PE period. The worker rejects PE.
Example: A qualified hospital PE provider submits a COMPASS PE/ongoing MA application for Jake, a 41-year old male, on October 2. The worker reviews the application and notices that Jake had been authorized for PE in January of the same year. The caseworker rejects the PE period, but reviews Jake’s application for ongoing MA eligibility.
The caseworker receives the PE application on the same day as the PE Begin Date and determines the individual ineligible for ongoing MA the same day.
Example: A qualified hospital PE provider submits a COMPASS PE/ongoing MA application on July 8. The PE Begin Date is July 8. The caseworker reviews and processes the application for ongoing MA eligibility on July 8. The worker determines the individual is not eligible for MA due to excess income verified through electronic data sources on July 8.
If the PE Begin Date is prior to the PE/ongoing MA application submission or the date the caseworker determines that the individual is not eligible for ongoing MA, a PE period must be authorized from the PE Begin Date. The caseworker must immediately process ongoing MA to close the PE period.
Example: A qualified hospital PE provider submits a COMPASS PE/ongoing MA application on March 14. The PE Begin Date is March 10. The caseworker reviews and processed the application on March 15. The caseworker verifies information through electronic data sources and determines the individual is not eligible for ongoing MA. The caseworker authorizes a PE period beginning March 10. The caseworker immediately processes ongoing MA. The system rejects ongoing MA and closes the PE Period.
If all required information has been provided with the PE/ongoing MA application, or the caseworker verifies required information electronically, and the individual is eligible, ongoing MA can be processed without a PE period, effective the PE Begin Date.
Example: A qualified hospital PE provider submits a PE/ongoing MA application on June 22. The PE Begin Date is June 18. The caseworker verifies all required information through electronic data sources and determines the individual is eligible for ongoing MA. The caseworker authorizes ongoing MA effective June 18.
Example: A PE provider of pregnancy services submits an MA332 for a pregnant woman with a PE Begin Date of January 12. The MA 332 is submitted with a PA600 HC on January 15. The PE provider attaches verification with the application. The caseworker determines the pregnant woman is eligible for ongoing MA effective January 12.
Reviewed May 3, 2024, Replacing July 18, 2019