The Balanced Budget Act of 1997 created Section 1920A of the Social Security Act which gives states the option of providing a period of presumptive eligibility to children when a qualified entity determines their family income is below the states applicable Medicaid or CHIP limit. This allows these children to receive medical care before they have formally applied for MO HealthNet. House Bill 1111 appropriated funds enabling Missouri to exercise this option. The income limit for presumptive eligibility in Missouri is 150% of the Federal Poverty Level (FPL) as that is the highest income limit that Missouri's MO HealthNet program covers without a waiting period.
In the Presumptive Eligibility for Children program, designated staff of "Qualified Entities" make limited eligibility determinations for children under age 19 who are Missouri residents. The Qualified Entity determines that a family meets the income guidelines of up to 150% of the Presumptive Eligibility for Children program and contacts the Family Support Division (FSD) to obtain DCNs. If eligible, the Qualified Entity provides the family with a presumptive eligibility authorization notice that reflects the DCN as the children's MO HealthNet number and an effective date of coverage. Presumptive Eligibility for Children is limited to once in a 12 month period.
The family uses this notice to obtain MO HealthNet covered medical services for the identified children from an enrolled MO HealthNet provider until receipt of the regular MO HealthNet card. This notice guarantees five days of coverage. After the 5th day, the provider is required to verify eligibility with MO HealthNet Division, as they do for any MO HealthNet for Kids (MHK) or MO HealthNet for Families (MHF) participant. These children will not be in managed care while they are on Presumptive Eligibility for Children.
Coverage continues until the last day of the month following the month of presumptive eligibility, unless the FSD determines eligibility or ineligibility for MO HealthNet prior to that date. Presumptive eligibility coverage ends on the date the child is approved or rejected for a regular Family Healthcare program.
Section 1920A of the Social Security Act allows states to determine the type of qualified entities to use. Currently, Missouri is limiting qualified entities to children's hospitals, Federally Qualified Health Centers (FQHCs), and Rural Health Clinics (RHCs). Prior to Senate Bill 577 (2007) only children's hospitals were designated as qualified entities.
Refer all requests to become a qualified entity to IM Program and Policy.
The qualified entity is responsible for screening all families who come to the entity for services to see if they are interested in healthcare coverage for their children.
If the family requests healthcare coverage for their children, the qualified entity will:
When determining the number of persons to include in the assistance group and whose income is considered, include children under 19 and their parents. The included person's income is considered in determining eligibility for presumptive. Non-parent caretakers and their income are excluded.
The qualified entity is also responsible to:
If the children (under age 19) are presumptively eligible, the entity will:
If the children are not eligible for Presumptive Eligibility, the qualified entity will:
Qualified entities contact the MO HealthNet Service Center for DCNs. MO HealthNet Service Center staff must carefully screen the applicant and provide a DCN if known, or assign a DCN if the applicant is not known to FSD.
MO HealthNet Service Center staff must also review IPAR and MXIX or IXIX screens for persons with DCNs to determine if the PE applicant received PE in the past 12 months. PE may only be granted one time in a 12 month period. If the applicant received PE in the past 12 months, the MO HealthNet Service Center staff informs the provider that this applicant is not PE eligible, as he or she received PE in the past 12 months.
PE for Children is indicated by Case ID or type of assistance (TOA) code of PC (Presumptive Eligibility for Children) on IPAR, MXIX and IXIX. The IPAR screen shows a case status of active or closed along with a closing date. The MXIX and IXIX screens show the case status as well as start and stop dates. If the PE case has been active in the 12 months prior to the screening date, the applicant is not eligible for presumptive eligibility.
Although qualified entities are instructed to contact the MO HealthNet Service Center for DCNs, if the qualified entity contacts the local FSD Office, a designated staff member at the local FSD office should screen for past PE eligibility and assign DCNs for the applicant(s) following the same procedures given above for MO HealthNet Service Center staff.
The FSD Office must contact local qualified entities to develop a procedure for the qualified entity to provide a daily exchange of Presumptive Eligibility Determination (PC-1) forms, Presumptive Eligibility MO HealthNet Authorization (PC-2) forms, and MO HealthNet Application (IM1UA) forms. The local FSD Office may designate a member of its staff to be a liaison with the qualified entity in the county. The responsibilities of the liaison are to provide technical assistance to the qualified entity, serve as a contact for the qualified entity on specific cases, and contact the qualified entity when made aware of any problems.
FQHCs and RHCs that signed agreements to determine PE have been added to the Presumptive Eligibility Qualified Entity List available under the Resource Link on FSD's MO HealthNet Intranet site at
http://dssweb/fsd/programs/mohealthnet/information/pe_qualified_entities.pdf
FSD county offices must develop procedures to ensure the faxed or submitted PC-1 and PC-2 is assigned to the appropriate eligibility specialist the same day it is received. The eligibility specialist must enter the PE determination into the Legacy system via IMU5 transaction the same day it is received.
NOTE: Eligibility determinations for PE for Children can be made by qualified entities only, not FSD staff. However, qualified entities do not have access to IMU5 and cannot enter the PE approval. FSD staff must do the data entry required to enter the approval in IMU5.
FSD is responsible for providing training when new contracted qualified entities sign agreements to begin processing applications for Presumptive Eligibility (PE) for Children. Once trained the FQHC/RHC trained staff may provide this training to other members of their staff. A qualified entity may also request and receive training from the liaison at the local FSD county office. A training packet is available at:
http://dssweb/fsd/training/IM/Other_Training_Packages/MHK_presumptive_elig/index.html.
NOTE: Once trained the FQHC/RHC trained staff may provide this training to other members of their staff, However, if the qualified entity has made errors in determining eligibility, the date on the authorization notice is incorrect, or other problems are identified, the FSD office should immediately discuss these problems with the qualified entity designated staff.
Applications may be received at the local FSD county office that are not for residents of that county. These applications should be handled as courtesy applications. Enter the Presumptive Eligibility (PE) for Children application on the day the PC-1 and PC-2 are received. Register the IM-1UA application and follow courtesy application procedures. Refer to FAMIS user guide Courtesy Applications for assistance with courtesy application procedures.
Presumptive Eligibility for Children determinations are entered in the Legacy system through IAPP and IMU5 transactions.
Enter the Presumptive Eligibility for Children into the Legacy system via an IMU5 transaction on the date the qualified entity notifies FSD of the determination.
Enter the IMU5 transaction for Presumptive Eligibility:
Field 5 - Case action (use IMU5 code sheet)
Field 6 - Reason open (use IMU5 code sheet)
Field 13E - date of eligibility for eligible child(ren)
Field 13G - level of care "T" for eligible child(ren)
Field 15b - Enter the QE provider number. This must be a valid provide number for the system to accept the entry.
Additionally, the MO HealthNet for Kids, Pregnant Women and Parents application (IM-1UA) that will be included with information from the qualified entity, must also be registered within one working day of receipt. The application date is the date the Presumptive Eligibility determination is made. The Presumptive Eligibility beginning date is the same date the IM-1UA is signed.
Qualified entities should submit Presumptive Eligibility determinations completed that reflect ineligibility to the local FSD county office for entry in the IMU5 system. The FSD county office staff will register a Presumptive Eligibility for Children application and enter a rejection in the system. It is necessary to enter the qualified entity number in field 15b when entering the rejection.
The system will only accept the following reason codes in field 7 of a Presumptive Eligibility rejection:
Keep all denial PC-1 forms in the file with the MO HealthNet case file.
The qualified entity is required to send the IM-1UA even if the child is found ineligible for Presumptive Eligibility for Children. Upon receipt, register and process the MO HealthNet for Kids, Pregnant Women and Parents (IM-1UA) application submitted with the Presumptive Eligibility for Children denial.
FAMIS sends a trigger to the Legacy system to close the Presumptive Eligibility for Children case the same day of the approval or rejection of the MO HealthNet application. Closings for Presumptive Eligibility for Children will be date specific. Eligibility Specialists may enter address changes and process case transfers on Presumptive Eligibility for Children cases using normal procedures
IM-1UA -- MO HealthNet for Kids, Pregnant Women and Parents application
Presumptive Eligibility Determination form -- PC-1
Presumptive Eligibility MO HealthNet Authorization -- PC-2
FSD supplies qualified entities with Presumptive Eligibility for Children eligibility determination forms (PC-1), the Presumptive Eligibility Authorization notices (PC-2), and (IM-1UA) MO HealthNet for Kids, Pregnant Women and Parents application. If a qualified entity contacts the county office to request a new supply of Presumptive Eligibility for Children (PC-1 and PC-2), or IM-1UA MO HealthNet for Kids, Pregnant Women and Parents forms, immediately provide the requested forms. Local FSD offices can obtain the (PC-1 and PC-2) forms from IM Program and Policy. The IM-1UA MO HealthNet for Kids, Pregnant Women and Parents application forms are obtained through the warehouse following normal ordering procedures.
The PC-1, PC-2 and IM-1UA forms and instructions are included in the qualified entity training packet and the IM Forms Manual.
Presumptive Eligibility for Children applicants do not have hearing rights regarding presumptive eligibility decisions made by qualified entities or ending dates of presumptive coverage. Qualified entities must always inform presumptive applicants their MO HealthNet for Kids, Pregnant Women and Parents application is being submitted to their local FSD county office for a determination of eligibility. Applicants for MO HealthNet for Kids, Pregnant Women and Parents have normal hearing rights on the MO HealthNet eligibility determinations.
Children determined presumptively eligible for MO HealthNet receive the same coverage (LOC 1) during the presumptive period. The children active under Presumptive Eligibility for Children are not enrolled in managed care. While the children must obtain their presumptive determination from a qualified entity, once eligible they can obtain covered services from any enrolled MO HealthNet fee-for-service provider. Coverage begins on the date the qualified entity makes the presumptive eligibility determination and coverage ends on the later of:
Presumptively eligible children are not regular MO HealthNet participants. Thus, children born to presumptively eligible children are not eligible for MO HealthNet coverage under the Newborn policy. If, at the time of birth, the presumptive eligible child (mother) has already been approved for regular MO HealthNet for Kids, Pregnant Women and Parents, the child born to the eligible child (mother) qualifies for MO HealthNet as a newborn.
A presumptive eligibility period has no effect on the beginning eligibility date of regular MO HealthNet coverage. Presumptive Eligibility does not have prior quarter eligibility. Explore prior quarter coverage under MO HealthNet for Kids, Pregnant Women and Parents, in the same manner as for any MO HealthNet application. Presumptively eligible children who are subsequently approved for MO HealthNet for Kids, Pregnant Women and Parents will have the beginning date of eligibility based on MO HealthNet for Kids (MHK) and MO HealthNet for Families (MHF) rules. In many cases, the MHK/MHF eligibility begin dates will be prior to the begin date of the presumptive eligibility period.