129.01 Presumptive Eligibility SR 13-35, 10/13 (MAM-A)

Presumptive eligibility (PE) is a process in which authorized qualified entities (community outreach providers who have attended DHHS training on presumptive eligibility policy) may make a PE decision for:

• Medical Coverage for Pregnant Women (MCPW) or Children’s Medicaid (CM), using DFA Form 800P, Application for Children’s Medicaid (CM) and Medical Coverage for Pregnant Women (MCPW); or

• Family Planning medical assistance, using DFA Form 800FP, Application for Family Planning Medical Assistance.

Presumptive eligibility is determined by the qualified entity (QE) worker who is acting on behalf of DHHS. The QE worker makes an eligibility determination following an interview with the applicant and based upon documentation collected from the applicant. In exchange for the QE acting on behalf of DHHS and making a decision that the applicant is eligible for Family Planning medical assistance, MCPW, or CM, the QE is guaranteed payment for covered services for a 10-day period. This 10-day period is called the 10-day PE eligibility period. The count begins with the date that the QE determines PE (this is day one), and ends 10 calendar days later. For example, the 10-day PE eligibility period ends on June 15 for an applicant who was determined presumptively eligible on June 6.

The 10-day verification and 45-day eligibility decision timeframes apply to PE determinations made by QE workers.

PE Process for MCPW or CM

Upon making a PE determination, the QE worker:

• indicates the PE decision on the completed and signed 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, the QE worker must:

1. Within 5 days, fax or email 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 used by the QE worker to make the PE determination; and

d. DFA Form 808P, Information Necessary to Support your Medical Coverage Application, if verifications are still needed; and

e. 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. Provide a copy of DFA Form 808P to the pregnant individual or the parent of the child determined eligible for medical assistance if verifications are still needed. Provide copies of DFA Form 800P and DFA Form 11 if requested.

3. Mail, within 10 days, the original DFA Form 800PEN, DFA Form 800P, DFA Form 808P, if used, DFA Form 11, and all required verifications, to: the Children’s Medicaid Unit (CMU), 129 Pleasant Street, Concord, NH 03301.

PE Process for Family Planning Medical Assistance

Upon making a PE determination, the QE worker:

• indicates the PE decision on the completed and signed DFA Form 800FP; and

• completes:

- DFA Form 806, Notice of Presumptive Eligibility Decision for Family Planning Medical Assistance;

- DFA Form 808FP, Information Necessary to Support your Family Planning Medical Assistance Application, if verification of eligibility is still outstanding; and

- DFA Form 11, Authorization to Release Information, to permit DHHS to share client information with the QE, if information sharing is desired by the client and QE.

Once the above is completed, the QE worker must:

1. Within 5 days, fax or email to the CMU all of the above forms, plus all the verifications that the QE used to make the PE determination.

2. Provide a copy of DFA Form 806 to the Family Planning medical assistance applicant so that the individual can present it to health care providers to document eligibility for medical assistance for the 10-day PE eligibility period.

3. Provide a copy of DFA Form 808FP to the Family Planning medical assistance applicant if verifications are still outstanding, and copies of DFA Form 800FP and DFA Form 11, if requested by the applicant.

4. Mail, within 10 days, the original the original DFA Form 800FP, DFA Form 806, DFA Form 808FP, DFA Form 11, if completed, and all verifications used to make the PE determination, to: the Children’s Medicaid Unit (CMU), 129 Pleasant Street, Concord, NH 03301.

All PE Determinations

The 10-day verification and 45-day eligibility decision timeframes apply to PE determinations. Upon receipt of the PE application package that the QE faxes or emails within 5 days of making the PE decision, the Family Services Specialist (FSS) must make a determination of eligibility for Family Planning, MCPW, or CM medical assistance within that 45-day timeframe. NOTE: QEs are not required to make PE determinations. If the QE chooses not to make a PE determination, the individual can still apply for Family Planning, MCPW, or CM medical assistance using DFA Form 800FP or DFA Form 800P. In these circumstances, DHHS will still have the 45-day period to make an eligibility decision, but the QE and client will not be provided with the 10-day PE eligibility period.

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 Family Planning medical assistance, 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.

PE medical assistance applications that have been forwarded by a QE worker authorized to determine PE must be screened by the FSS for completeness. A valid application is one that contains the applicant’s name, address, and the signature of the applicant or their authorized representative. The FSS reviews the application and other submitted information, requests missing verification (if applicable) from the QE or client, and processes the application in accordance with policy. The official filing date of the application is either:

• the date that the QE worker interviewed the client and signed the DFA Form 800P or DFA Form 800FP; or

• the date the valid DFA Form 800P or DFA Form 800FP was received by the CMU, if completed and submitted directly by the applicant.

Policy about presumptive eligibility will change under the Affordable Care Act (ACA) effective January 2014. This policy will be updated to incorporate these changes at that time.