SR 15-07 Dated 01/14

STATE OF NEW HAMPSHIRE

INTER-DEPARTMENT COMMUNICATION

SUMMARY

This SR releases presumptive eligibility (PE) policy for categories of Medicaid that use modified adjusted gross income (MAGI) in the eligibility determination process. These changes in PE policy reflect Affordable Care Act (ACA) reforms implemented at 42 USC 1396r-1, 42 USC 1396r-1a, 42 USC 1396r-1c, and 42 CFR 435.1101 - 42 CFR 435.1110, subsequent guidance from the Centers for Medicare & Medicaid Services (CMS), and NH decisions related to those reforms, as realized at PART He-W 843. The PE policy released in this SR is only applicable to certain MAGI-related medical assistance coverage groups, and does not apply to any category of Medicaid that does not use MAGI in the eligibility determination process.

An entity or hospital that furnishes health care services and is enrolled with DHHS to receive Medicaid payments as a Medicaid provider, must do the following if they wish to determine PE:

·      notify DHHS that they wish to determine PE via providing DHHS with a completed DFA Form 820, Request to Determine Presumptive Eligibility (PE);

·      attend a training on the eligibility criteria for MAGI medical coverage groups and score an 85% or higher on a written exam following the training;

·      maintain their certification by, among other requirements, applying PE eligibility requirements consistently and accurately during each PE determination, verifying that the individual is authorized for the PE period, and verifying that the individual is not already a Medicaid applicant; and

·      participate in retraining and retesting, and may be disqualified from determining PE, if DHHS finds that the certified entity or hospital fails to adhere to the requirements of determining PE.

Entities and hospitals who are successfully certified by DHHS are referred to as qualified entities (QEs) and qualified hospitals (QHs) and are certified to make PE determinations for a limited period of temporary medical assistance coverage. This temporary PE medical coverage is provided to individuals who have been determined to have met PE eligibility requirements on the basis of limited, preliminary, self-attested information provided by the PE applicant on new DFA Form 821, Application for Medicaid Presumptive Eligibility (PE), for the following MAGI-related medical assistance coverage groups only:

·      Children’s Medicaid (CM), Expanded CM, and Children with Severe Disabilities (CSD);

·      Pregnant Women Medical Assistance (MA);

·      Family Planning Medical Assistance (FPMA);

·      Parent/Caretaker Relative MA; and

·      NH Health Protection Program (NHHPP/NHHPP-M).

Note: Certified QHs, but not certified QEs, can additionally determine PE for Former Foster Care Child MA.

There is a single, simplified PE eligibility process that is used for all categories of Medicaid for which PE is applicable. The following DFA forms and their associated instructions have been created to support the updated PE policy and are used in that single PE eligibility process:

·      DFA Form 820, Request to Determine Presumptive Eligibility (PE);

·      DFA Form 821, Application for Medicaid Presumptive Eligibility (PE); and

·      DFA Form 822, Notice of Presumptive Eligibility (PE).

The following forms and their associated instructions are now obsolete due to the creation of the forms above and the policy released in this SR:

·      DFA Form 800PEN, Notice of Presumptive Eligibility (PE);

·      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; and

·      DFA Form 808P, Information Necessary to Support Your Medical Assistance Application.

Note: The following forms are not obsolete and will still be used:

·      DFA Form 800, Application for Assistance, and DFA Form 800MA, Application for Health Coverage & Help Paying Costs, to apply for any category of MA; and

·      DFA Form 800FP, Application for Family Planning Medical Assistance (FPMA), to apply for FPMA.

To apply for PE, an individual must:

·      Complete new DFA Form 821, Application for Medicaid Presumptive Eligibility (PE); and

·      Submit the completed DFA Form 821 to a certified QE or QH.

Individuals are limited to one PE period per calendar year or, if pregnant, one PE period per pregnancy.

DHHS-certified QHs and QEs make PE eligibility determinations based upon the applicant’s self-attested preliminary income, citizenship, household composition, and residency information that the applicant entered on DFA Form 821. There are no further verification requirements for applicants of PE.

The PE period begins on the date the individual is determined eligible for PE by the QE/QH, and ends on:

·      the date the determination of eligibility, or ineligibility, for full Medicaid is made by DHHS, if an application is filed by the last day of the month following the month in which the determination of PE is made; or

·      the last day of the month following the month in which the determination of PE is made if no application is filed by that date.

This SR also releases policy for PE certification of QHs and QEs, maintaining QH/QE PE certification and QH/QE disqualification for determining PE.

BACKGROUND

Federal regulations amended by the Affordable Care Act of 2010 (ACA), the collective term used to refer to the Patient Protection and Affordable Health Care Act (PL 111-148) and the Health Care and Education Reconciliation Act (PL 111-152), required states to allow any hospital interested in determining PE to do so. New Hampshire chose to elect the option of allowing certain other agencies, such as family planning agencies, to participate in determining PE as well. DHHS is responsible for training and certifying hospital/agency workers prior to allowing them to become certified in determining PE.

POLICY

PE Process

Presumptive Eligibility (PE) is a period of temporary medical assistance coverage provided to individuals who have been determined as meeting eligibility requirements on the basis of limited, self-attested, preliminary information that is provided by the PE applicant. PE is available to the following MAGI-related medical assistance groups:

·      Children’s Medicaid (CM), Expanded CM, and Children with Severe Disabilities (CSD);

·      Pregnant Women MA;

·      Parent/Caretaker Relative MA;

·      Family Planning MA;

·      NH Health Protection Program (NHHPP/NHHPP-M); and

·      Former Foster Care Child Medical Assistance.

Individuals are limited to one (1) PE period per calendar year or, if pregnant, one (1) PE period per pregnancy. This means:

·      an individual who was determined eligible for PE on July 25, 2015 would not be eligible for another PE period until January 1, 2016;

·      a pregnant individual who was determined eligible for PE on July 25, 2015, would not be eligible for another PE period until:

-     she experiences a new pregnancy in 2015; or

-     January 1, 2016 or later if she is no longer pregnant.

·      an individual who was determined eligible for PE on July 25, 2015 (whether based on pregnancy or not), and then became pregnant in December, would be eligible for another PE period beginning with the date of her pregnancy in December of 2015.

Note: Individuals are no longer required to have an intervening period of receipt of medical assistance for which DHHS has conducted a full Medicaid eligibility determination and verified all pertinent eligibility criteria prior to receiving another period of PE.

There is a single, simplified PE eligibility process for all categories of Medicaid for which PE is offered. To apply for PE, an individual must:

·      complete new DFA Form 821, Application for Medicaid Presumptive Eligibility (PE); and

·      submit the completed DFA Form 821 to a certified Qualified Entity (QE) or Qualified Hospital (QH).

The QE/QH helps the individual complete the PE application. The QE/QH is not required to collect any additional verification of the self-attested information entered onto DFA Form 821 from the individual. However, the QE/QH must verify that the individual is not already a Medicaid recipient and is eligible to receive another PE decision, per the PE period limitations stated above. The certified QE/QH worker is required to explain that this PE application is not an application for Medicaid, and that a Medicaid application must be filed before the end of the PE period or his or her medical assistance will stop.

The QE/QH worker reviews the information on the completed PE application and makes an eligibility determination. If the individual is determined eligible, the QE/QH worker submits, within 5 days of the determination date, the completed DFA Form 821 and DFA Form 822 to the Main (or any) District Office. When received, the DHHS worker enters the information from the submitted DFA Form 821 into New HEIGHTS using the PE determination date as the application filing date. This date is also the PE begin date.

Note: Since the PE applicant does not need to provide any verification during the PE eligibility determination process, the 10-day verification deadline does not apply to PE. Similarly, because the PE applicant is merely applying for PE and not applying for full Medicaid during the PE process, the 45-day eligibility timeframes also do not apply - unless or until the PE applicant/recipient applies for full Medicaid using DFA Form 800MA or DFA Form 800. Once the individual submits an application for full Medicaid, however, the 10-day verification and 45-day eligibility decision timeframes do still apply.

The QE/QH is guaranteed payment for covered services for the length of the PE period, which begins on the date the QE/QH worker determines the individual eligible for PE and ends either:

·      the date the determination of eligibility or ineligibility for full Medicaid is made, if an application for Medicaid is filed by the last day of the month following the month in which the determination of PE is made; or

·      the last day of the month following the month in which the determination of PE is made, if no application for Medicaid is filed by that date.

QE/QH workers determine if an individual is eligible for PE based on the following self-attested, limited, preliminary PE information provided by the PE applicant:

·      the individual meets the categorical requirements for the appropriate MAGI-related coverage group;

·      household income does not exceed the applicable income standards for the applicable household size and MAGI-related coverage group;

·      the individual attests to being a New Hampshire resident; and

·      the individual attests to US citizenship, or satisfactory immigration status.

Upon a QE/QH worker’s approval of PE for the applicant, the QE/QH worker:

·      indicates the PE decision on the individual’s completed DFA Form 821;

·      completes DFA Form 822, Notice of Presumptive Eligibility (PE);

·      faxes or emails DFA Form 821, DFA Form 822, and, if necessary, DFA Form 11, Authorization to Release Information, to the Main (or any) District Office, within 5 days of the PE determination; and

·      provides the original DFA Form 822 to the individual who was determined eligible for PE so that the individual can present it to health care providers and pharmacists to document PE eligibility until the Medicaid ID card or DFA Form 809, Proof of Family Planning Medical Assistance (FPMA), is received in 5-10 days, or until a previously issued Medicaid card is reactivated.

Upon receipt of DFA Form 821 from the certified PE worker at a QH or QE, the DHHS worker enters the information listed on DFA Form 821 into New HEIGHTS. No verification of this information is required during the PE period.

Upon a QE/QH worker’s denial of PE, the QE/QH worker is required to provide a PE denial notice, which notifies the individual that:

·      the individual is ineligible for PE; but that the individual can still apply for Medicaid by submitting an application to DHHS; and

·      the individual cannot file an administrative appeal of the PE denial, as the administrative appeal requirements do not apply to PE determinations.

The QE/QH is guaranteed payment for covered services for the length of the PE period which begins on the date the individual is determined eligible for PE, and ends on:

·      the date the determination of eligibility, or ineligibility, for full Medicaid is made by DHHS if an application is filed by the last day of the month following the month in which the determination of PE is made; or

·      the last day of the month following the month in which the determination of PE is made if no application is filed by that date.

Examples:

An individual is determined eligible for PE on June 1st.

·      The individual does not file an application for Medical Assistance during the PE period. This individual’s PE period will end on the last day of the PE period, July 31st.

·      The individual files an application for Medical Assistance on June 3rd, and is determined ineligible for Medicaid on June 10th. This individual’s PE period ends on June 10th.

·      The individual files an application for Medical Assistance on June 3rd, and is determined eligible for Medicaid on June 12th. This individual’s PE period ends on June 12th.

·      The individual files an application for Medical Assistance on July 31st, and is determined ineligible on August 25th. This individual’s PE period ends August 25th.

QE and QH Certification

For a QE or QH to become certified by DHHS, the organization must complete the following steps:

·      the organization formally notifies DHHS that they are interested in determining PE by completing DFA Form 820, Request to Determine Presumptive Eligibility (PE);

·      the organization’s employees who wish to determine PE must attend a PE training session provided by DHHS; and

·      at least one of the organization’s employees must score 85% or higher on a written exam provided by DHHS after the PE training session.

Only the QE and QH employees who attend a PE training session and score 85% or higher on the written exam are certified to determine PE.

Both QEs and QHs must maintain their certification by, among other requirements, applying PE eligibility requirements consistently and accurately during each PE determination, verifying that the individual is authorized for the PE period, and verifying that the individual is not already a Medicaid applicant. QHs have an additional certification requirement. For a QH to maintain certification, at least 75% of the individuals the QH has determined eligible for PE must submit a Medicaid application before the end of the individual’s PE period. If a QH does not meet this requirement, the QH must send all employees who have been certified to determine PE to an additional PE training and/or testing offered by DHHS.

If DHHS determines that the QE or QH is failing to adhere to the requirements of determining PE, the QE/QH:

·      must participate in retraining within 30 days of the date of the notice from DHHS that the QE/QH is not meeting requirements; and

·      score an 85% or higher on the written reexamination provided at the retraining.

The QH or QE will be disqualified from determining PE if:

·      all certified employees do not attend the additional training and/or testing session within timeframes and achieve a score of 85% or higher on the written reexamination; or

·      all certified employees attend the additional training and/or testing session, but the QH still fails to meet the requirement that 75% of the individuals they have determined eligible for PE must submit applications for Medicaid before the end of the individual’s PE period.

QE/QHs are disqualified for a:

·      6-month period from the date on the disqualification notice from DHHS for the first finding; and

·      1-year period from the date on the disqualification notice from DHHS for the second and subsequent findings.

NEW HEIGHTS SYSTEMS PROCEDURES AND IMPLEMENTATION

New HEIGHTS will automate PE, effective April 24, 2015, for all MAGI-related medical assistance groups by:

·      updating the eligibility system to limit the amount of required information necessary to confirm the opening of PE to only the information required on the PE application, DFA Form 821, Application for Medicaid Presumptive Eligibility (PE); and

·      adding a new check box entitled “Presumptive” to the Request For Assistance (RFA) Client Registration screen which, when selected, will automatically default to certain PE-correct answers and will allow the worker to enter all information without having to navigate through and answer the usually required eligibility questions on the screens in the driver flow. Once “Presumptive” is check on the Client Registration screen, the MAGI-only switch will default to “checked” and a Family Planning Only switch will be available on the Program of Assistance (POA) screen.

Other New HEIGHTS changes or procedures needed to implement the new PE policy include:

·      On the “Additional Demographics” screen workers will need to:

-     select “I don’t remember” if a SSN has not been provided;

-     select “yes” to the US Citizen question;

-     respond “yes/no” to the NH Residency question, per the applicant’s self-attestation on the submitted DFA Form 821;

-     answer questions on the Household Relationship screen as a “non-filer” for the PE application. (However, tax information will be entered when a Medicaid application is received.);

-     default to “In Apartment, House, etc.” on the Living Arrangement screen; and

-     mark the current enrollment status for school age children as “Full Time” and non-school age children as “Not Enrolled” on the Education Screen.

·      A new Individual Screen titled “Presumptive Application” will appear in the driver flow after the “Additional Demographics” screen if the Presumptive box is checked for the Medicaid request on the POA screen. The “Presumptive Application” screen will capture the PE application information at the individual level as well as required details of the organization requesting PE on behalf of an applicant and will include a:

-     case “Go to” box which will launch the screen out of the driver;

-     Summary tab listing only the individual’s latest PE request, the History Sequence Number of the PE request, the name of the individual requesting PE, and the individual’s application date; and

-     Details Tab displaying the standard case header and individual header and a Presumptive Application section including the following fields and subsections: Application Dates. The begin date (date of PE determination) is mandatory and worker populated. The end date is mandatory and automatically pre-populated to the last day of the month following the begin date’s month. Example: If the begin date is 1/15/15, the end date populates as 2/28/15.

·      The new “Presumptive Application” screen will also include the following additional questions with yes/no options:

-     Has the individual been approved for PE within the last calendar year?

-     Is the individual a recipient of Medicare?

-     Is the individual a parent or caretaker relative? If the answer to this question is “yes”, the following fields become mandatory with a yes/no dropdown menu: Is the individual disabled or incapacitated?, Is the individual working less than 100 hours per month?, and Is the individual unemployed?

·      On the “Pregnancy” screen, the following new question has been added: “Has the individual been approved for PE during this pregnancy?”

The following changes will allow the Training Unit to collect data in New HEIGHTS relating to the organization/PE worker that is requesting PE for an individual:

·      by clicking the “find” button, the ‘Maintain Representative’ pop-up box will appear. The search criteria will be defaulted to search by organization. This will display the results of the certified QE/QH for PE and:

-      when the Training Unit selects the correct organization, the QE/QH information including the organization’s ID will populate; and

-      when the Training Unit saves the organization’s information, the ID will be linked to the individual record in the PE application table.

·      two (2) free form text fields will allow the Training Unit to enter the certified QE/QH organization, name, and certification number;

·      a new mandatory drop-down field labeled “PE Qualified Type” will be added next to the address field and will list the following options from a new RT TPQT:

·      the dropdown depicted in the chart above will only be visible and editable by the Training Unit; and

·      the data captured via the above dropdown will be used to track the organization’s performance based on the organization’s type (meeting and maintaining PE certification requirements).

As soon as staffing and resources allow, the same changes for determining PE will be made to NH EASY.

Once all necessary information has been entered per the new PE process on the PE application screens in New HEIGHTS and the PE period has been confirmed:

·      a Medicaid card will be issued to individuals who are full Medicaid PE recipients and have not been issued a Medicaid card in the last 12 month period;

·      individuals who are full Medicaid PE recipients and have had a Medicaid card issued within the last 12 month period will have that existing Medicaid card activated; or

·      individuals who are Family Planning PE recipients will receive New HEIGHTS-generated AE0124, Proof of Family Planning Medical Assistance (FPMA).

New HEIGHTS will automatically terminate or deny PE:

·      when the case is either approved or denied Medicaid, if an application has been filed at any point during the PE period. The below special text will appear on any open/deny MA NOD sent out when an individual was open for PE:

A decision has been made on your application for Medicaid. Because of this, your Presumptive Eligibility (PE) period has ended. You can only get PE once per calendar year, or per each new pregnancy. You cannot appeal the ending of your PE. If you were denied for Medicaid, you can ask to appeal that denial per the directions in this notice. PE will not stay open while you wait for your appeal hearing. 42 CFR 435.1101, 42 CFR 435.1102(e), 42 CFR 435.1103, PART He-W 843

Note: if a new application is filed during the PE period, but the ‘regular’ MA AG(s) have not been confirmed open, New HEIGHTS will deny the pending ‘full’ application at the same time the closure job is run to end PE.

·      on the last day of the month following the month the PE determination was made for all who did not submit an application for Medicaid. No NODs will generate under this circumstance.

The following special messages will be populated on the open PE NOD generated out of New HEIGHTS:

You are presumptively eligible (PE) for medical coverage. PE is temporary. If you do not want your medical coverage to end, you must apply for Medicaid. Visit our website at http://www.dhhs.nh.gov/dfa/apply.htm to print out an application, or contact us at 1-800-852-3345 Ext. 9700 to apply by phone. Your PE will end the last day of next month unless you apply for Medicaid on or before that date. You will not get another letter from us to tell you that your PE is ending. This is the only notice you will get about when your PE ends. You cannot appeal the ending of your PE. If you apply for Medicaid on or before the date your PE ends, your PE period will not end until a determination is made on your Medicaid application. You can only get one PE approval per calendar year, or per each new pregnancy. 42 CFR 435.1101, 42 CFR 435.1102(e), 42 CFR 435.1103, PART He-W 843

Refer to the New HEIGHTS system alert dated April 27, 2015 for more details of the changes.

DESCRIPTION OF NEW FORMS

The following DFA forms and their associated instructions have been created to support the updated PE policy.

DFA Form 820

DFA Form 820, Request to Determine Presumptive Eligibility (PE), is a one-page, single sided paper application used by hospitals and other organizations to petition DHHS to become a certified Qualified Entity (QE) or Qualified Hospital (QH). Certification by DHHS allows the QE/QH to determine presumptive eligibility for MAGI-related medical assistance groups. To become certified for determining PE, employees of hospitals or organizations must attend a training given by DHHS and score at least 85% on a written test. Only the employees who attend the training and score 85% or higher on the written exam can determine PE.

An individual representing the hospital or organization that is interested in being certified as a QE/QH completes DFA Form 820 by providing the individual’s:

·      name and title;

·      hospital/provider name;

·      business street address and e-mail address;

·      business phone and fax number; and

·      preferred method of contact.

The individual signs DFA Form 820 thereby indicating that they understand the requirements and the related responsibilities of becoming certified as a QE/QH. Their signature further indicates that they are formally notifying DHHS that they want to become trained and certified to be able to determine PE. The individual also indicates on the form whether they are choosing to determine PE for Medicaid and optional FPEC, or FPEC only, and how many employees will attend the DHHS training.

When completed, the hospital or organization:

·      mails DFA Form 820 to the DCS Training Unit, 64 South St., Concord, NH 03301; or

·      faxes DFA Form 820 to 271-0647.

Upon receipt of the completed form, the DCS Training Unit will schedule a training and testing session for PE certification.

DFA Form 820 is retained for three years from the date of completion in the Training Unit’s files.

This form will not be translated. Instructions for this new form were created accordingly. DFA Form 820 is available in the DHHS Warehouse and can be ordered on behalf of the QEs/QHs using the regular Quarterly Forms Order (QFO) process. This form is also available electronically, for DHHS staff only, on the Lotus Notes Family Services Database, and on the DHHS website at: http://www.dhhs.nh.gov/dfa/presumptive/forms.htm.

DFA Form 821

DFA Form 821, Application for Medicaid Presumptive Eligibility (PE), is a 1-page, double-sided paper application used by a QE/QH to collect information to determine PE for all MAGI-related medical assistance groups except Former Foster Care Child MA. Only a QH can determine PE for FFCC MA. The completed DFA Form 821 is returned to the Main District Office or any other District Office within five (5) days of the date of determination of PE. Upon receipt of completed DFA Form 821, DHHS workers enter the information into New HEIGHTS using the date the certified PE worker entered as the presumptive eligibility begin date on the bottom of the back-side of DFA Form 821 as the application filing date.

The PE applicant provides the following information on DFA Form 821:

·      The PE applicant’s name, contact information, email address, and primary language;

·      The PE applicant and applicant’s family member’s:

-     name;

-     Social Security Number (optional);

-     date of birth;

-     relationship to the PE applicant;

-     pregnancy status and number of babies expected, if pregnant; and

-     income information.

·      The following PE applicant’s information, and information for any family member who is also applying for PE on the same application:

-     citizenship status;

-     residency;

-     Medicaid recipient status;

-     New Hampshire foster care status;

-     whether any individual applying for PE has received a PE period during the current calendar year, or if pregnant, during the current pregnancy;

-     Medicare status; and

-     parent or caretaker relative status (unemployment status, incapacity status, and/or if working less than 100 hours per month).

The QE or QH worker provides the following information on DFA Form 821:

·      the names of all individuals the QE/QH determined eligible for PE, and whether the PE period is for FPMA only;

·      the PE begin date for each individual determined eligible for PE;

·      the dated signature and printed name of the certified PE worker; and

·      the QE/QH’s provider number and email address.

The QE/QH worker then sends this form, along with DFA Form 822, to the Main (or any) District Office, within 5 days of making the PE determination.

This form has been translated into Spanish and Nepali. Instructions for DFA Form 821 were created accordingly.

A small supply of DFA Form 821 is provided to QEs and QHs upon request at trainings, but the form is also available in the DHHS Warehouse and can be ordered using the QFO. Additionally, this form is available electronically, for DHHS staff only, on the Lotus Notes Family Services Database, and on the DHHS website at: http://www.dhhs.nh.gov/dfa/presumptive/forms.htm.

DFA Form 822

DFA Form 822, Notice of Presumptive Eligibility (PE), is a 1-page, double-sided paper form that is used by QEs/QHs that determine eligibility for PE for MAGI-related medical assistance groups. This form serves as verification of an individual’s PE eligibility for Medicaid service providers until the PE recipient receives a Medicaid ID card, or DFA Form 809, Proof of Family Planning Medical Assistance (FPMA).

·      QEs/QHs complete DFA Form 822, Notice of Presumptive Eligibility (PE), by entering on the form:

-     the name of the individual who completed DFA Form 821, Application for Medicaid Presumptive Eligibility (PE). This person is considered the head of household;

-     the date the PE determination was made (this is the PE effective date);

-     the name, DOB, SSN and Medicaid ID number (MID) if known (because the PE recipient previously had a Medicaid card) for each person who has been determined by the QE/QH to be presumptively eligible;

-     the QE’s/QH’s business name, phone number fax number, and mailing address;

-     the name of the QE/QH worker completing DFA Form 822, Notice of Presumptive Eligibility, and his or her dated signature; and

-     the head of household’s signature and signature date, acknowledging the Statements of Understanding have been explained to him or her and that he or she understands them;

·      the QE/QH explains the application process for full Medicaid or FPMA and provides all necessary forms to complete that application process;

·      the QE/QH faxes DFA Form 821, Application for Medicaid Presumptive Eligibility (PE), DFA Form 822, and DFA Form 11, Authorization to Release Information, if needed, to the Main (or any) District Office: (603) 271-8604 (Fax for Main District Office).

·      the QE/QH provides the original DFA Form 822, Notice of Presumptive Eligibility (PE), to the head of household, and explains that this original form must be presented to health care providers and pharmacists so that they can receive Medical services until they receive their Medicaid ID card or DFA Form 809, Proof of Family Planning Medical Assistance (FPMA), in 5 to 10 days, or until a previously issued Medicaid ID card is reactivated.

·      within 5 days of making the PE eligibility determination, the QE/QH mails the original DFA Form 821, Application for Medicaid Presumptive Eligibility (PE), a copy of DFA Form 822, Notice of Presumptive Eligibility (PE), and DFA Form 11, Authorization to Release Information, to the:

Main District Office

64 South Street

Concord, NH 03301

·      the DHHS worker files the copy of DFA Form 822 in the client’s case file where it is retained for 3 years.

There are no plans to translate this form. Instructions for DFA Form 822 were created accordingly.

DFA Form 822 is an electronic form and available, for DHHS staff only, on the Lotus Notes Family Services Database; it will not be stored in the DHHS Warehouse. It is also posted on the DHHS website at: http://www.dhhs.nh.gov/dfa/presumptive/forms.htm.

If ineligible for PE, the QE/QH worker is responsible, per 42 CFR 435.1102(b)(v) for providing the ineligible PE applicant with a PE denial notification. The letter is used solely by QEs/QHs that determine PE for MAGI-related medical assistance groups and serves as the individual’s official notification of PE denial. This letter is not provided by DHHS or processed by DHHS staff.

The PE denial notification is completed by the QE/QH worker who is denying PE for the individual and records the following information:

·      the name of the person who completed DFA Form 821, Application for Medicaid Presumptive Eligibility (PE), who is considered the head of household;

·      the date of the PE denial;

·      the name, DOB, and SSN of each person requesting PE assistance (and the Medicaid ID number (MID) if the individual previously had a Medicaid card);

·      the reason explaining why PE was denied:

-     the household’s income exceeds the income limits for this program, and the chart explaining the income budget;

-     the individual[s] are already getting Medicaid;

-     the household does not meet the eligibility requirements for the type of Medicaid;

-     the individual already had a PE period during the current calendar year; or

-     the individual already had a PE period during this current pregnancy.

·      the clearly printed or typed agency name, phone number, fax number, and mailing address along with the name of the person completing the form; and

·      the QE/QH worker’s dated signature.

The QE/QH worker must:

·      explain the statements of understanding to the individual, who signs and dates the form;

·      explain the application process for full Medicaid or FPMA to the individual, and provide all necessary forms to complete the application process if the individual requests the forms;

·      provide the original PE denial letter to the head of household; and

·      keep a copy of the denial letter for the QE/QH’s records. This form is not retained in any DHHS case file.

This notification is not a DHHS form as each QE/QH will be responsible for drafting a supplying this notification.

Obsoleted Forms

The following forms and their associated instructions are now obsolete due to the creation of the forms above and the policy released in this SR:

·      DFA Form 800PEN, Notice of Presumptive Eligibility (PE);

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

·      DFA Form 808P, Information Necessary to Support Your Medical Assistance Application; and

·      DFA Form 808FP, Information Necessary to Support Your Family Planning Medical Assistance Application.

Recycle the forms listed above immediately. A Certificate of Destruction has been included with this SR.

POLICY MANUAL REVISIONS

Revised Adult Assistance Manual Topics

Section 305.05  Verification of Citizenship and Identity

Revised Family Assistance Manual Topics

PART 131  ELIGIBILITY DETERMINATIONS

Section 301.07  Verification of Identity

Section 305.05  Verification of Citizenship

Revised Medical Assistance Manual Topics

PART 121  INITIATION OF MEDICAL ASSISTANCE

Section 129.01  Presumptive Eligibility

PART 177   PRESUMPTIVE ELIGIBILITY (PE)

Section 177.01  MAGI-Related Coverage Groups Eligible for PE

Section 177.03  PE Determination Process

Section 177.05  Length of PE Period

Section 177.07  Certification Process to Determine PE

Section 177.09  Maintaining QH/QE Certification to Determine PE

Section 227.21  Family Planning MA Determining Presumptive Eligibility (PE)

Section 303.05  Verification of Citizenship and Identity

IMPLEMENTATION

The policy released in this SR is effective January 1, 2014. The forms that have been created to support the policy released in this SR are effective April 24, 2015 or upon receipt, whichever is earlier. DFA Forms 800PEN, DFA Form 806, DFA Form 808FP, and DFA Form 808P, and their associated instructions, are obsolete upon release of this SR and should be destroyed immediately. A Certificate of Destruction has been included in this SR.

CLIENT NOTIFICATION

No special client notification is planned or needed. Administrative rules have been promulgated to adopt new PART He-W 843, PRESUMPTIVE ELIGIBILITY FOR MAGI-RELATED COVERAGE GROUPS. At release, however, these rules have not yet been reviewed by the Joint Health Care Reform Oversight (JHCRO) Committee, as required by RSA 161:11. Once this committee has reviewed and commented upon the rules, the rules will then need to be reviewed by the Medical Care Advisory Committee (MCAC), to carry out the provisions at 42 CFR 431.12. As such, it is unclear when a public hearing on the proposed rules may be held, but at this point it will be scheduled no earlier than summer 2015.

TRAINING

DHHS held trainings and written exams beginning in December 2013 for QE/QHs who expressed interest in becoming certified to determine PE. DHHS is continuing certification training and testing on an as needed basis.

FORMS MANUAL POSTING INSTRUCTIONS

DISPOSITION

This SR may be destroyed or deleted after its contents have been noted and the revised manual topics released by this SR have been posted to the On-line manuals.

DISTRIBUTION

This SR will be distributed according to the electronic distribution list for Division of Family Assistance policy releases. This SR, and revised On-Line Manuals, will be available for agency staff in the On-Line Manual Library, and for public access on the Internet at www.dhhs.nh.gov/DFA/publications.htm, effective June 1, 2015. Additionally, this SR, and printed pages with posting instructions, will be distributed under separate cover to all internal hard copy holders of the Adult Assistance, Family Assistance, Medical Assistance and Forms Manuals.

DFA/KD:s