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MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services H-200 Medical Assistance Manual HOSPITAL PRESUMPTIVE ELIGIBILITY 23 Oct 01 MTL 04/23 OVERVIEW

PRESUMPTIVE ELIGIBILITY DWSS CASE MANAGER GUIDANCE

H-200 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 get access to immediate coverage and to promote ongoing Medicaid enrollment, by encouraging individuals to complete a full application for health insurance with DWSS.

H-201 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 Finance & 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 (PE) Medicaid provider contract amendment in place with DHCFP. Provider of hospital staff making the PE determination must be trained and certified by the DWSS Learning and Development unit to obtain PE system access to the DWSS Portal.

H-205 ELIGIBLE GROUPS

Qualified providers and hospitals participating in the PE program may make presumptive eligibility determinations for the following eligibility groups. Eligibility for medical assistance is categorized in groups based on the budgeting methodology associated with the eligibility determination.

a. Children (This group only covers children approved for the CH and/or CH1 categories. Hospitals do not make determinations for Nevada Check Up.)

b. Parents and caretaker relatives

c. Pregnant women (Providers can approve prenatal services, hospitals can approve full PE).

d. Childless adults age 19-64

e. Aged Out of Foster Care