131.01 Presumptive Eligibility SR 12-04, 07/12 (FAM-A)

Presumptive eligibility is a process in which a qualified entity (community outreach agency staff who have attended DFA training on presumptive eligibility policy) makes a preliminary eligibility decision for MCPW or *CM using DFA Form 800P, Application for *Children’s Medicaid (CM) and Medical Coverage for Pregnant Women (MCPW). Presumptive eligibility is determined by the community outreach agency staff member following an interview with the applicant and based upon documentation available at the interview.

The 10-day verification and 45-day eligibility decision timeframes apply to presumptive eligibility determinations made by community outreach agency staff.

Upon making a determination of presumptive eligibility, the community outreach agency staff person:

• indicates the presumptive eligibility decision on DFA Form 800P; and

• completes DFA Form 800PEN, Notice of Presumptive Eligibility Decision for Children’s Medicaid (CM) and Medical Coverage For Pregnant Women (MCPW).

Once DFA Form 800PEN is completed, community outreach agency staff must:

1. Fax the following information to *the Children’s Medicaid Unit (CMU):

a. the completed DFA Form 800P;

b. the completed DFA Form 800PEN;

c. any verifications; and

d. DFA Form 11, Authorization to Release Information.

2. Provide a copy of DFA Form 800PEN to the pregnant individual or the parent of the child determined eligible for medical assistance so that the individual can present it to health care providers and pharmacists to document eligibility for medical assistance until the Medicaid ID card is received in 5-10 days or until a previously issued card is activated.

3. Mail, within 10 days, the original DFA Form 800PEN, DFA Form 800P, DFA Form 11, and all required verifications, to: *the Children’s Medicaid Unit, 129 Pleasant Street, Concord, NH 03301.

The community outreach agency has 5 working days to provide a notice of determination for presumptive eligibility to the individual and the District Office using DFA Form 800P. The District Office must make a determination of eligibility within the 45-day timeframe.

Consecutive presumptive eligibility determinations are prohibited without an intervening period of receipt of medical assistance for which the District Office has conducted a full eligibility determination and verified all pertinent eligibility criteria. Once an individual has been determined presumptively eligible for *CM or MCPW, that individual is eligible for another presumptive eligibility determination only after the individual:

• has been determined eligible for medical assistance by the DHHS District Office and received such assistance after the presumptive eligibility period ended; and

• subsequently becomes ineligible for medical assistance.