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MRG

UPDATED: AUGUST 1999

702

OTHER ELIGIBILITY REQUIREMENTS PRESUMPTIVE ELIGIBILITY

NURSING FACILITY, HOSPICE OR HOME HEALTH CARE SERVICES

Policy: Presumptive eligibility is Medicaid coverage provided to certain applicants who reasonably appear to meet all of the criteria, financial and non-financial, pending the completion of the full eligibility determination.

Presumptive eligibility for nursing facility, hospice or home health care services is available to persons meeting the following criteria:

(1) the applicant is receiving care in an acute hospital at the time of application;

(2) a physician certifies that the applicant no longer requires acute hospital care, but requires the type of medical care provided by a Certified Home Health Agency (CHHA), a Long Term Home Health Care Program (LTHHCP), nursing facility or hospice;

(3) the applicant or his/her representative states that there is insufficient insurance coverage for this type of care and that the applicant would not otherwise be able to pay for that required care;

(4) it appears that 65% of the cost of care provided by the nursing facility or hospice, would be less than the cost of continued hospital care computed at the Medicaid rate (alternate care rate); and

(5) the applicant appears to meet all the criteria, financial and non-financial, for Medicaid. A screening checklist is used to eliminate those cases from the presumptive eligibility process which require in-depth reviews to determine eligibility.

Persons applying for presumptive eligibility for home health care services are budgeted as community cases. They are not considered to be in chronic care.

A period of presumptive eligibility begins on the date of discharge from the hospital and continues for sixty (60) days or until the standard eligibility determination is completed, whichever is earlier.