177.03 PE Determination Process (MAM)

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A Qualified Hospital (QH) or Qualified Entity (QE) determines if an individual is eligible for presumptive eligibility (PE) based on the following self-attested, limited, preliminary PE information provided by the applicant on DFA Form 821, Application for Medicaid Presumptive Eligibility (PE):

. categorical requirements for the applicable MAGI-related coverage group;

. household income and HH size;

. NH residency status; and

. US citizenship or acceptable immigration status.

PE applicants are not required to provide any further information or verification.

Prior to making a PE eligibility determination, QHs and QEs verify that the PE applicant:

. is not already a Medicaid recipient;

. is not currently covered in a PE period; and

. has not already had a PE period for:

- this calendar year; or

- if pregnant, for this pregnancy.

If the QH or QE determines an applicant eligible for PE based on acceptable eligibility information as listed above, the QH or QE worker must:

. fax or e-mail copies of the completed PE application including the eligibility decision, DFA Form 822, Notice of Presumptive Eligibility (PE), and if necessary, DFA Form 11, Authorization to Release Information, to the Main DO (or any other DO) within 5 days of the PE determination; and

. provide the original DFA Form 822 to the individual for use at health care providers and pharmacies as verification of their PE eligibility until a new Medicaid card or DFA Form 809, Proof of Family Planning Medical Assistance (FPMA), is received within 5-10 days, or until a previously issued Medicaid card is reactivated. (Recipients of Family Planning Medical Assistance (FPMA) can only receive services from family planning clinics, not other pharmacies or Medicaid providers.)

Upon receipt, DO workers enter the information from the individual's PE application into New HEIGHTS. No further verification of this information is required during the PE period.

If an applicant is determined ineligible for PE, the QE or QH worker must provide the individual with a PE denial notice stating that the individual:

. is not eligible for PE;

. can still apply for Medicaid; and

. cannot file an administrative appeal of the PE denial, per 42 CFR 435.1102(e).

References: He-W 843.02, 42 CFR 435.1100-435.1110