All Medicaid Programs

Obsolete Policy

 

Obsolete 0419 - 356 Presumptive Eligibility

Effective Date:  March 1, 2017 - March 31, 2019

 

Previous Policy for BYB and HPE  (Contact DOH Program Specialist for previous PE policy by DHS)

 

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.

 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:  

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

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

Child Medicaid 0-5 (CM 0-5)

Child Medicaid 6-18 (CM 6-18)

Parent Caretaker Relative (PCR)

Pregnant Women (PW)

Former Foster Care

 Eligibility Requirements

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

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

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

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

Not been denied for Medicaid, CHIP, UPP or PCN within the past 30 days, unless the household circumstances have changed.

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

A woman can only receive PW once per pregnancy.

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

Medical Support Enforcement is not required for PE programs.

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

The PE provider did not submit the application to the eligibility agency within 5 business days of the PE determination date.

An individual is known to be an undocumented alien.

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

The PE provider did not respond to the eligibility agency within 2 business days of their request for additional information on an incomplete application.