Obsolete 0221 - 356 Presumptive Eligibility (PE)

Effective Date: June 1, 2020 - January 31, 2021

PE allows eligible individuals to receive temporary medical assistance while eligibility is being determined for ongoing medical coverage. Unless otherwise stated, Medicaid eligibility rules apply. Additional program requirements can be found in the BYB and HPE Training Manuals.

A. Program Types

PE is divided into two programs: Baby Your Baby (BYB) and Hospital Presumptive Eligibility (HPE). Both programs are administered by PE providers as outlined below:

1. BYB is administered by qualified health care providers. BYB providers determine eligibility for Pregnant Women (PW) medical assistance.

2. HPE is administered by qualified hospitals. HPE providers determine eligibility for the following medical assistance programs in order of hierarchy:

· Child 0-5 (CM 0-5)

· Child 6-18 (CM 6-18)

· Parent Caretaker Relative (PCR)

· Pregnant Women (PW)

· Former Foster Care (FFC)

· Adult Expansion

· COVID-19 Uninsured Testing Coverage

B. Eligibility Requirements

1. Eligibility is based on an individual’s statement. Do not request verification from an individual applying for PE.

2. In addition to meeting residency and citizenship/alien status requirements in section 200, an individual must meet the following:

a. Gross household income at or below the income limit for the specific medical assistance program (Table VII)

· COVID-19 does not have an income test - see section C.

b. Not currently covered on Medicaid, CHIP, UPP or Medicaid with a spenddown, even if the spenddown has not been met.

c. Not denied for Medicaid, CHIP or UPP, within the past 30 days unless the household circumstances have changed or if applying for COVID-19 Uninsured Testing Coverage.

d. For PW, a woman must be pregnant at the time of application.

e. A woman can only receive PW once per pregnancy.

f. Except for PW, an individual can only receive HPE once per calendar year.

3. Medical Support Enforcement is not required for PE programs.

4. The following are circumstances when the eligibility agency can override a PE provider’s decision:

a. An individual is currently receiving Medicaid, CHIP, UPP or Medicaid with a spenddown, even if the spenddown has not been paid.

b. The form 40 is submitted after the ongoing medical determination (approval or denial) has been made.

C. COVID-19 Uninsured Testing Coverage

During the COVID-19 emergency period, individuals can apply for and receive temporary PE coverage through the current HPE providers.

1. Eligibility for all other medical programs must be looked at first before determining eligibility for COVID-19 Uninsured Testing Coverage.

2. Individuals must meet residency and citizenship/alien status requirements.

3. There are no income, asset or age limits.

4. Individuals must be uninsured.

· Individuals receiving Medicaid, CHIP, Medicare, TRICARE, Veterans Administration, a federal employee health plan, group health plan or health insurance coverage offered by a health insurance issuer including a qualified health plan through an Exchange, employer-sponsored health insurance, retiree health plans or COBRA coverage do not qualify.

· Individuals enrolled in a limited-benefit Medicaid eligibility group are not considered insured. Limited-benefit insurance includes plans that only cover certain diseases, such as cancer. Limited benefit Medicaid groups include individuals infected with tuberculosis.

5. Individuals can apply online through the Presumptive Eligibility Portal (PEP). The application also serves as an ongoing medical application unless the individual opts out.

· There is no limit to the number of times an individual can apply.

6. Eligibility is determined by current HPE providers.

7. Coverage begins on the eligibility start date indicated on the form 40.

8. Eligible individuals receive coverage through the PE period unless DWS approves ongoing medical or until a designated UDOH staff member extends eligibility through the end of the month in which the emergency period ends.

· Individuals whose coverage will close at the end of the PE period should be referred to UDOH to determine ongoing coverage.

9. The COVID-19 Uninsured Testing Coverage application and form 40 are sent to DWS through PEP.

· DWS enters the eligibility decision into eRep.

· DWS registers the ongoing medical application unless the individual opts out.

· DWS sends the COVID-19 Uninsured Testing Coverage approval or denial notice to the individual(s).