66.03 Procedures

In general.105 AHS will provide Medicaid services to an individual during the presumptive-eligibility period that follows a determination by a qualified hospital that, on the basis of preliminary information, the individual has gross income at or below the Medicaid income standard established for the individual. (b) AHS’s responsibilities.106 AHS will: 105 42 CFR § 435.1102(a). 106 42 CFR § 435.1102(b). Eligibility-and-Enrollment Procedures Part 7 – Page 49 (Sec.66.00, Sub.66.03) Provide qualified hospitals with application forms for Medicaid and information on how to assist individuals in completing and filing such forms; Establish oversight mechanisms to ensure that presumptive-eligibility determinations are being made consistent with applicable laws and rules; and Allow determinations of presumptive eligibility to be made by qualified hospitals on a statewide basis. (c) Qualified hospital’s responsibilities107 On the basis of preliminary information, a qualified hospital must determine whether the individual is presumptively eligible under this rule. For the purpose of the presumptive eligibility determination, a qualified hospital must accept self- declaration of the presumptive-eligibility criteria. If the individual is presumptively eligible, a qualified hospital must: (i) Approve presumptive coverage for the individual; (ii) Notify the individual within twenty-four hours of the eligibility determination, in writing or orally, if appropriate: That the individual is eligible for presumptive coverage; The presumptive eligibility determination date; That the individual is required to make application for ongoing Medicaid by not later than the last day of the following month; and That failure to cooperate with the standard eligibility determination process will result in denial of ongoing Medicaid and termination of presumptive coverage on the date described in § 66.04; (iii) Notify AHS of the presumptive eligibility determination within five working days after the date on which determination is made; (iv) Provide the individual with a Medicaid application form; (v) Advise the individual that: If a Medicaid application on behalf of the individual is not filed by the last day of the following month, the individual’s presumptive eligibility will end on that last day; and If a Medicaid application on behalf of the individual is filed by the last day of the following month, the individual’s presumptive eligibility will end on the day that a decision is made on the Medicaid application; and (vi) Take all reasonable steps to help the individual complete an application for ongoing Medicaid or 107 42 CFR § 435.1102(b)(2), as applied to hospital determination of presumptive eligibility by 42 CFR § 435.1110(a). Eligibility-and-Enrollment Procedures Part 7 – Page 50 (Sec.66.00, Sub.66.04) make contact with AHS. If the individual is not presumptively eligible, a qualified hospital must notify the individual at the time the determination is made, in writing and orally if appropriate: (i) Of the reason for the determination; (ii) That their ineligibility for presumptive coverage does not necessarily mean that they are ineligible for other categories of Medicaid; and (iii) That the individual may file an application for Medicaid with AHS, and that, if they do so, that the individual’s eligibility for other categories of Medicaid will be reviewed. A qualified hospital may not delegate the authority to determine presumptive eligibility to another entity.108 (d) Required attestations.109 For purposes of making a presumptive eligibility determination under this section, an individual (or another person having reasonable knowledge of the individual's status) must attest to the individual being a: Citizen or national of the United States or in satisfactory immigration status; and Resident of the state. (e) Limitation on other conditions110 The conditions specified in this subsection are the only conditions that apply in the case of a presumptive- eligibility determination. Verification of the conditions that apply for presumptive eligibility is not required.