Obsolete 0523 - 356 Presumptive Eligibility(PE)

Effective Date: February 1, 2021 - May 11, 2023

Introduction

Presumptive Eligibility (PE) is temporary Medicaid coverage for individuals determined presumptively eligible by qualified, trained Baby Your Baby (BYB) and Hospital Presumptive Eligibility (HPE) Providers. PE consists of two programs:

· Baby Your Baby: eligibility for Pregnant Women, and

· Hospital Presumptive Eligibility: eligibility for PCR, Child, Pregnant Woman, Adult Expansion, Former Foster Care, and Uninsured COVID 19 Testing.

BYB and HPE Providers use self-attested information provided on the PE application to determine eligibility for one of the allowed PE Medicaid coverage groups. A PE application also serves as an ongoing medical application unless the individual opts out. Unless otherwise stated, Medicaid eligibility rules apply. The BYB and HPE Training Manuals contain additional program and provider requirements https://medicaid.utah.gov/medicaid-z/. PE individuals do not have rights to a fair hearing.

A. Application for BYB or HPE

1. Applications for HPE and BYB are completed through the Presumptive Eligibility Portal (PEP) https://medicaid.utah.gov/byb-info.

· Individuals can apply for BYB independently, or

· A BYB Provider can complete an application on behalf of the individual as long as the individual signs the application.

· HPE Providers create applications on behalf of the individual. The individual must sign the application.

2. DWS will make a full Medicaid decision on any paper applications requesting PE. PEP sends the PE Provider’s eligibility decision (approval or denial) to DWS.

3. If approved for PE, coverage begins the day the provider makes the PE decision.

4. DWS enters the eligibility decision into eREP.

· DWS sends the PE decision notice to the individual.

· Unless the individual opts out, DWS registers the PE application and makes a determination for ongoing medical coverage.

o For approved PE applications, coverage continues until the day DWS makes a decision for ongoing medical coverage.

o For denied PE applications, DWS determines ongoing medical unless the individual opts out.

o DWS sends its decision notice about ongoing medical coverage to the individual.

5. If the individual opts out of the ongoing medical determination, PE ends on the last day of the month following the month the provider makes the PE decision.

B. Eligibility Criteria

1. Baby Your Baby

a. In addition to meeting residency and citizenship/non-citizen status requirements in section 200, a woman must:

· Have a gross household income at or below 139% FPL (Table VII)

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

· Not have received a denial for Medicaid, CHIP or UPP within the past 30 days, unless the household circumstances have changed.

· Be pregnant at the time of application.

· Only receive BYB once per pregnancy.

b. There is no asset test.

c. Do not require a pregnant woman to comply with Medical Support Enforcement for BYB, or for ongoing Medicaid until after the post-partum period ends.

2. Hospital Presumptive Eligibility

a. HPE Providers determine eligibility only for the following Medicaid programs:

· Child 0-5

· Child 6-18

· Parent/Caretaker Relative

· Pregnant Woman

· Former Foster Care

· Adult Expansion

· COVID-19 Uninsured Testing Coverage

b. In addition to meeting residency and citizenship/non-citizen status requirements in section 200, an individual must meet the following eligibility for all program types except for COVID-19 Uninsured Testing Coverage (357) :

· Have a gross household income at or below the income limit for the program type (Table VII).

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

· Not have received a denial 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.

· For Pregnant Woman PE Medicaid, a woman must be pregnant at the time of application.

· A woman can only receive Pregnant Woman HPE once per pregnancy.

c. There is no asset limit.

d. Medical Support Enforcement is not required for any HPE programs. In addition, do not require a pregnant woman to comply with Medical Support Enforcement for HPE, or for

e. Except for PW HPE, an individual can only receive HPE once per calendar year.Women can receive PW HPE one time per pregnancy.

C. Overriding a Presumptive Eligibility Decision

The PE Provider’s decision is final and cannot be changed unless an approved individual is currently receiving Medicaid, CHIP, UPP, or is eligible for Medicaid with a spenddown even if the spenddown has not been met.