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West Virginia Income Maintenance Manual Chapter 1
West Virginia Income Maintenance Manual Page 134 Chapter 1 Application/Redetermination Process
1.6.11.B Presumptive Eligibility Individuals receiving services through a Qualified Provider who are interested in applying for Medicaid may apply with the assistance of an Authorized Employee. Qualified Providers may elect to provide Presumptive Eligibility (PE) determinations to individuals who are without any other form of health coverage. Additional information about Qualified Providers can be found in Chapter 400 of the West Virginia Medicaid Provider Manual. Presumptive Eligibility (PE) is not permitted for any other program. It is unrelated to Presumptive Medical decisions for the Medical Review Team (MRT). Eligibility is established on date of determination. Back-dating does not apply to this provision. Coverage groups eligible for PE: • Children under age 19 • Pregnant Women • Parents/Caretaker Relatives • Adult Group • Former Foster Children • Breast and Cervical Cancer (BCC) women receiving current treatment Presumptive Eligibility is limited to once every twelve months, with the exception of pregnant women, who are eligible once per pregnancy. ➢ Duties of the Authorized Employee The Authorized Employee, which could also include the DOHS hospital employee, makes a PE decision based on preliminary information provided by the individual seeking treatment, or his Authorized Representative (AR) (someone with the patient who would reasonably be expected to know about the individual seeking benefits, including attesting to the individual’s U.S. citizenship or satisfactory immigration status). The Authorized Employee is prohibited from requiring any other verification prior to approval. Additional information gathered includes name, household size, income limit, sex, address, and prior approval for PE in the last 12 months. Using the same WV PATH portal as Community Partners, the Authorized Employee sends the information electronically to the eligibility system and issues a Medical ID card with a PE Medicaid ID. The period of eligibility begins on the date of determination and ends on the last day of the next month, or when a full Medicaid application determination is made, whichever occurs earlier. The decision is not subject to fair hearing rights and advance notice is not required.