All Medicaid Programs |
Obsolete Policy |
Effective February 1, 2016 - June 30, 2016
What is Presumptive Eligibility?
Presumptive Eligibility (PE) allows clients to receive temporary medical assistance while the eligibility agency (The Dept. of Workforce Services-DWS) determines their eligibility for ongoing Medicaid or CHIP.
The Department of Health will designate qualified hospitals to determine Presumptive Eligibility for the following coverage groups. Hospitals may not delegate authority to determine PE eligibility to non-hospital employees. Hospitals must have a formal agreement in place with the Department of Health.
Child 0-5
Child 6-18
Pregnant Woman
Former Foster Care Individuals
Parent/Caretaker Relative
General Eligibility Requirements
To qualify for the presumptive eligibility program, a client must meet the following general requirements based on preliminary information received by qualified hospitals:
Be a U.S. citizen or a qualified alien
Be a Utah resident
Have a gross household income at or below the federal poverty limit for the specific PE program
Must not already be covered on Medicaid, CHIP, UPP, PCN, or approved for Medicaid with a spenddown.
Must not have received a denial for Medicaid, CHIP, UPP, or PCN within the past 30 days unless the household circumstances have changed.
There is no resource test for PE.
There is no presumptive eligibility for the medically needy coverage group.
TPL (Third Party Liability) information is not an eligibility requirement for Medicaid PE; do not deny PE for failure to provide TPL. It is optional for the client to provide TPL for Medicaid PE.
For ongoing Medicaid, TPL must be verified and referred.
Household Size
Determine the household size using the following guidelines. Include only people who live together.
Child 0-5
Applicant
Applicant’s parent(s) and step-parent(s)
Applicant’s sibling(s) and step-sibling(s) under age 19
Child 6-18
Applicant
Parent(s) and step-parent(s)
Legal spouse of applicant(s)
Applicant’s unborn child(ren)
Siblings and step-siblings under age 19
Pregnant Woman
If the pregnant woman is under age 19
Applicant
Legal spouse of applicant(s)
Applicant’s parent(s)
Applicant’s unborn child(ren)
Children including step-child(ren)
Siblings and step-siblings under age 19 if applicant is age 18 or younger
If the pregnant woman is age 19 or older
Applicant
Legal spouse of applicant(s)
Applicant’s unborn child(ren)
Children including step-child(ren)
Former Foster Care Individuals
Applicant
Parent/Caretaker Relative
Applicant
Legal spouse of applicant
Applicant’s unborn child(ren) if they are in the third trimester of pregnancy
Children including step-child(ren)
Whose Income to Count
Count the gross income (before taxes) of everyone that is included in the household size for the specific program with the following exceptions.
Do not count the income of a child to another child (sibling)
Do not count the income of a child to a parent
Do not count the income of a guardian to the child(ren) that the guardian is responsible for.
Exempt Income
The following types of income are exempt when determining eligibility for BYB.
Veteran's income
Educational income
Child support
Specific Eligibility Requirements
Child 0-5
Income limit: 139% of the FPL
A child can receive eligibility through the month he/she turns 6
A child does not have to live with a parent or specified relative
Child 6-18
Income limit: 133% of the FPL
A child can receive eligibility through the month in which he/she turns 19
If an 18 year old child lives with his/her parents, the parents’ income is countable
This program overrides the Pregnant Woman program
Pregnant Woman
Income limit: 139% of FPL
The woman must be pregnant
If a pregnant woman is 19 years of age or older, her parents’ income is not countable
If a pregnant woman is under 19 years of age and she lives with her parents, her parents’ income is countable.
Former Foster Care Individuals
Age 18-26
Eligibility can run through the month the individual turns 26
Was concurrently enrolled in Medicaid and foster care at age 18 or higher when foster care ended
Was in state custody or an Indian tribe when foster care ended. Persons in the custody of Juvenile Justice Services are not eligible
May not be eligible for another category of HPE Medicaid coverage
Parent/Caretaker Relative
Household must include a child that is under age 18 or is age 18 AND a full time student expected to graduate before age 19
Deprivation of support must exist due to a deceased, incapacitated, or underemployed parent.
Hierarchy of Medicaid Programs
When a client qualifies for more than one HPE program type, use the following hierarchy to determine which program type to approve.
Child 0-5 or Child 6-18
PCR
Pregnant Woman
Former Foster Care Individuals
Medicaid PE Determination
The hospital must make a PE decision and notify the Department within 5 business days from the date of determination.
The applicant must provide all PE information that the hospital needs to determine presumptive eligibility.
The PE determination is based on the customer’s declaration; no verifications are needed.
A client can only receive one period of presumptive eligibility in a calendar year for all PE coverage groups except pregnant woman
· A client can only receive Pregnant Woman PE once per pregnancy.
Example 1: A client applies for PE and is approved for PCR in February. Ongoing PCR is approved, but it closes two months later due to an increase in income. The client returns in August and is pregnant. She applies for pregnant woman PE and is approved. Although she cannot receive PCR PE again in the same calendar year, she can receive pregnant woman PE in the same year, because these programs are considered separately.
Example 2: A client applies for and is approved for pregnant woman PE in March. She has the baby in June. In November, she applies and is approved for PCR PE. Because Pregnant Woman PE is considered separately from other PE coverage groups, she can receive PE twice in the same year.
Medicaid Period of Presumptive Eligibility
Presumptive Eligibility begins on the day that the hospital determines a client is eligible.
Presumptive Eligibility ends on the day that the DWS completes an eligibility decision for regular medical assistance, or on the last day of the month following the PE approval month if an application for ongoing medical assistance has not been submitted.
When a client is approved for presumptive eligibility and applies for medical assistance, presumptive eligibility continues only until DWS makes an eligibility decision based on that application. Filing additional medical applications does not extend the presumptive eligibility period.
If more time is needed to determine medical assistance eligibility, the worker must grant a monthly extension.
Notices
If a client is determined presumptively eligible, inform the customer in writing:
That presumptive eligibility ends on the day DWS completes an eligibility decision for regular medical assistance, or on the last day of the month following the PE approval month if an application for ongoing medical assistance has not been submitted.
If a client is determined not presumptively eligible, inform the customer in writing:
The denial reason, and
That the application for regular medical assistance has been forwarded to DWS; and DWS will send a notice of decision based on that medical application.
Appeal Rights
The standard notice and appeal rights do not apply to decisions about Presumptive Eligibility.
Benefit Start Date for Ongoing Medical
When a presumptively eligible client is determined eligible for ongoing Medicaid, the benefit start date is either the first day of the application month subject to the limitations in Medicaid section 711, or the first day of any of the retroactive months in which the client is eligible.
When a presumptively eligible client is eligible for ongoing CHIP, see CHIP policy 701-2 to determine the benefit start date for CHIP.
Opting Out of Ongoing Medical Assistance
A client may choose to opt out of applying for ongoing medical assistance when applying for presumptive eligibility.