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Division of Welfare and Supportive Services H-115 Medical Assistance Manual PRESUMPTIVE ELIGIBILITY 23 Oct 01 MTL 04/23 VERIFICATION H-115 VERIFICATION

Qualified providers and hospitals are prohibited from requiring individuals to provide verification of any eligibility factors used in a PE determination. Hospitals must accept client attestation.

Note: If the individual provides any type of verification, a copy of the verification needs to be retained with the application.

H-120 PE COVERAGE PERIOD

The PE period begins the day of application and ends the last day of the month following the first month of the eligibility determination, if a full application for health insurance is not received by DWSS for the individual. If a full application for health insurance is received during the PE period, PE ends the day DWSS approves or denies the full application.

Example: A PE determination is made on January 10th and no health insurance application is received. Medicaid eligibility begins January 10th and ends February 28th. The system will automatically terminate eligibility, requiring no action by DWSS staff.

Example: A PE determination is made on February 10th and a full DWSS application for health insurance application is received on March 2nd. DWSS processes the application on April 10th. PE ends April 10th.

Individuals approved for Hospital PE are eligible for one (1) PE period every 24 months.

Pregnant individuals and individuals approved under the Prenatal Pregnancy PE program may receive one (1) PE period for each separate pregnancy.

Both PE programs, Prenatal and Hospital, will count against the other program’s restricted time limit.

Note: Adverse action notification is not required when ending a PE period after the denial of the DWSS application for full health insurance.

H-125 NOTIFICATION OF PE DETERMINATION

Qualified providers and hospitals are required to provide a written notification of the PE eligibility determination through a Notice of Decision (NOD) to individuals and families applying for PE. The NOD must advise the applicant of the eligibility determination, the appropriate PE period and the option for individuals or families to submit a complete health insurance application to DWSS. The PE Notice of Decision (Form 2991) will be provided to the qualified providers and hospitals by DWSS.

The requirement to provide a notice and fair hearing regulations and appeal rights does not apply to the PE determination.