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DMA ADMINISTRATIVE LETTER NO: 18-13, PROVIDER INSTRUCTIONS FOR PRESUMPTIVE ELIGIBILITY FOR PREGNANT WOMEN

DATE:

May 28, 2014

SUBJECT:

Provider Instructions for Determining Presumptive Eligibility for Pregnant Women

DISTRIBUTION:

Enrolled Presumptive Eligibility Providers

County Directors of Social Services

Medicaid Eligibility Staff

I. Background

II. PROVIDER ENROLLMENT PROCESS

III. Applicant/Beneficiary Eligibiilty Requirements

IV. Provider Instructions

Counting Income Tax Household

 

Tax Filer(s)

Tax Dependent – child of tax filer – does not meet an exception

Tax Household

Count income of tax filer and spouse in home, if not in tax household.

Only count income of tax dependents who expect to file a tax return.

Count income of tax filer(s)

Count income of the tax dependent applicant, and other tax dependents who expect to file a tax return. Count the income of the tax dependent’s spouse if not included in the tax household.

Counting Income Non Filer

 

Tax Dependent – not child of tax filer

(non-filer rules)

Adult – age 19 or older

Medicaid age child – under age 19

Non-filer rules

Count income for own household regardless of whether they expect to file taxes and count income of live-in spouse.

If the tax dependent has children under age 19 in the household, count income of children under age 19 if they expect to file return.

If the tax dependent is under age 19 ( see last column for Medicaid age child-under age 19)

Count income of applicant and spouse, if in home.

Count income of children in household under 19 only if expect to file return

If parent(s) is not in the household count income for own household regardless of whether they expect to file taxes and count income of live in spouse and live in siblings under age 19.

If the Medicaid age child has children under age 19, count income of children under age 19 if expect to file return.

If parent(s) is in the household, count the income of the parent(s). Do not count income of the child or siblings under age 19 unless the child/siblings expects to file a tax return.

NUMBER IN FAMILY

196% of the Federal Poverty Level

2

$2,570

3

$3,233

4

$3,896

5

$4,559

6

$5,222

7

$5,885

8

$6,549

V. EXAMPLES

Medicaid Household

Anna

Rudy

Family Size

Countable Income

Anna

    X + 1

    X

    3

    $2750

         

Medicaid Household

Samantha

Sandy

Ben

Family Size

Countable Income

Samantha

    X + 2

    X

    X

    5

    $1200

           

VI. Provider instructions for approving/Denying eligibility

VII. Presumptive Eligibility Period

VIII. Appeal Rights

If you have any questions regarding this information, please contact the Division of Medical Assistance at (919) 855-4000.

(This material was researched and written by Christine Coffey, Policy Consultant, Medicaid Eligibility Unit.)

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  For questions or clarification on any of the policy contained in these manuals, please contact your local county office.


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