Page 3

MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL MEDICAL Division of Welfare and Supportive Services H-220 Medical Assistance Manual HOSPITAL PRESUMPTIVE ELIGIBILITY 23 Oct 01 MTL 04/23 HPE COVERAGE PERIOD

application for medical assistance is not received by DWSS for the individual. If a full application for medical assistance is received during the HPE period, HPE ends the day DWSS approves or denies the application.

Example: HPE determination is made on January 10th and no medical assistance 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: PE determination is made on February 10th and a full medical assistance application is received on March 2nd. DWSS processes the application on April 10th. Presumptive eligibility ends April 10th.

Note: Adverse action is not required when ending a presumptive eligibility period by denying the medical assistance application.

DWSS case managers are not required to update the HPE determination in the system. When the full application for medical assistance is processed, using all current eligibility policies, the system will update the PE determination automatically.

Example: PE determination was made in January and the full medical assistance application was received in January, but not processed until March. Case manager would post application month of January and ongoing regardless of the PE determination. This will allow DHCFP and their MMIS system to adjust the eligibility status and retroactively claim the appropriate federal match rates for newly eligible individuals.

H-225 NOTIFICATION

Qualified providers and hospitals are required to provide written notification of the eligibility determination (Notice of Decision) to individuals applying for PE.

The notice must:

a. advise the applicant of the eligibility determination; and b. the PE period; and c. the importance of submitting a complete medical assistance application

Notice and fair hearing regulations do not apply to the PE determination. The PE Notice of Decision (form 2991) will be provided to qualified providers and hospitals by DWSS.