Family and Children's Medicaid MA-3245 PRESUMPTIVE ELIGIBILITY FOR PREGNANT WOMEN

03/01/02

I. OVERVIEW

A. The Division of Medical Assistance may contract with certain qualified medical providers to determine presumptive eligibility for pregnant women.

It is the provider’s responsibility to determine presumptive eligibility and notify the county dss in the pregnant woman’s county of residence. The county department of social services and its employees cannot determine presumptive eligibility.

B. The qualified provider who opts to determine presumptive eligibility must enroll with and be approved by DMA. Examples of qualified providers are community health centers, health departments, rural health clinics and other providers who receive maternal and child health funding. A list of enrolled Presumptive Eligibility Providers is updated regularly and issued by DMA Administrative Letter.

C. The qualified provider determines presumptive eligibility, by using the Presumptive Eligibility Determination Form (DMA-5032) for limited Medicaid benefits based on three eligibility criteria: pregnancy, income and living arrangement. The woman’s pregnancy must be medically verified; her family income, based on her statement, must be equal to or below the 185% poverty income level; and the pregnant woman can not be an inmate of a public institution.

D. If the pregnant woman is determined presumptively eligible for Medicaid, the provider refers her to the county department of social services to apply for Medicaid. The pregnant woman is advised to apply for Medicaid no later than the last work day of the month following the month she is determined presumptively eligible.

E. If the pregnant woman fails to apply for Medicaid or Work First within this time period, she is eligible for limited Medicaid only through the last calendar day of the month following the month she is determined presumptively eligible.

F. If the pregnant woman applies for Medicaid within this time frame, she remains presumptively eligible for Medicaid until the county makes a determination on her application.

G. During the presumptive eligibility period, Medicaid will cover only ambulatory prenatal services provided by any Medicaid enrolled provider. This includes prescriptions.

H. Presumptive eligibility is limited to one presumptive eligibility period per pregnancy.

03/01/12

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