Eligibility Online Manual
M1811 Presumptive Eligibility (PE)
Purpose: This section will assist in determining eligibility for Presumptive Eligibility.
Current Policy Effective Date: February 14, 2022
Date Last Reviewed: July 19, 2024
Previous Policy: October 1, 2016
POL 1811: DETERMINING ELIGIBILITY FOR PRESUMPTIVE ELIGIBILITY
1. Presumptive Eligibility Determinations Are Made By Qualified Providers Or Qualified Hospitals
Qualified Providers can process PE applications for the Pregnant Woman program only.
Qualified Hospitals can process PE applications for the following programs:
Pregnant Woman
Child MAGI
Family MAGI
Breast and Cervical Cancer
Former Foster Youth
KidCare CHIP
2. Applicants Must Meet All Eligibility Criteria Set For The Full Medicaid Program
Applicants must meet all eligibility criteria for the full Medicaid program but no verifications are required.
3. Benefits Begin The Day The PE Application Was Submitted If Determined Eligible
4. There Are No Retroactive Benefits For PE
5. Clients May Lose Benefits
Benefits will close on the last day of the month after the PE approval, if no full Medicaid application is received.
PE benefits will close when a determination is made on the full Medicaid application, if one is received.
6. PE Periods Are Limited
One PE benefit period is allowed per pregnancy.
One PE benefit period is allowed per year for all other PE groups.
7. The Medicaid Streamlined Application Is Required To Obtain Full Medicaid.
Reference: 42 CFR 435.110
42 CFR 435.907
1902 (a) (47) and 1920 of the Act
Clarifying Information:
1. All information gathered for PE is based on self-declaration, information is not verified.
2. Qualified Hospitals must meet standards established by the state.
3. A corrective action plan will be established for Qualified Hospitals who do not meet the standards established by the state.
4. PE for pregnant woman only covers ambulatory outpatient services. All other PE groups have the same coverage as their full Medicaid program.