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H-100 Division of Welfare and Supportive Services PRESUMPTIVE ELIGIBILITY Medical Assistance Manual OVERVIEW 23 Oct 01 MTL 04/23 PRESUMPTIVE ELIGIBILITY PROVIDER GUIDANCE

H-100 OVERVIEW

Presumptive Eligibility (PE) allows qualified providers and hospitals to determine certain individuals “presumptively eligible” for Medicaid based on preliminary information obtained from the applicant. Individuals determined eligible for PE receive Medicaid benefits for a temporary period of time, provided all eligibility criteria is met.

The purpose of PE is to provide a streamlined process for individuals to obtain access to immediate coverage and to promote ongoing Medicaid enrollment by encouraging individuals to complete a full application for health insurance with DWSS.

Questions regarding all PE or Medicaid policy listed in this Medicaid Assistance Manual (MAM) should be directed to the DWSS Chief of Eligibility and Payments or the DWSS Medicaid Program Specialist.

H-101 QUALIFIED PROVIDERS / QUALIFIED HOSPITALS

A qualified provider or hospital participates as a provider under the State Medicaid Program and must agree that they will make PE determinations consistent with state policies and procedures outlined in both the Division of Health Care Financing and Policy (DHCFP) Medicaid Services Manual (MSM) and the Division of Welfare and Supportive Services (DWSS) Medicaid Assistance Manual (MAM).

Each provider or hospital electing to participate in the PE program must have a signed Presumptive Eligibility Medicaid provider contract amendment in place with DHCFP. Hospital staff making the PE determination must be trained and certified by the DWSS Learning and Development unit to obtain system access to the DWSS PE Portal.

Qualified Provider or Qualified Hospital Requirements

DHCFP and DWSS will determine the appropriate Medicaid provider types for each PE program. Selected providers must be publicly available and must allow any individual or family to request a PE application and determination be made for them regardless of whether the individual or family is a current patient of the provider or hospital.

There are differences in the PE program that a qualified Provider or a qualified Hospital may approve:

• qualified providers may approve Prenatal Pregnancy PE only. • qualified hospitals may approve full Health Care Services (Hospital PE)