Family and Children's Medicaid Admin. Letters

ADMINISTRATIVE LETTER NO: 04-08, Provider Instructions for presumptive eligibility

DATE: 03/20/2008

SUBJECT: Provider Instructions for Determining Presumptive Eligibility

DISTRIBUTION: Enrolled Presumptive Eligibility Providers

County Directors of Social Services

Medicaid Eligibility Staff

The purpose of this letter is to revise procedures for Presumptive Eligibility because of a change in state policy. Current Medicaid budgeting rules require that the income of a putative father count when making presumptive eligibility determinations. A putative father is one who is not married to the pregnant woman but who is the supposed father of the unborn child. A recent review of Federal law revealed that including the income of a putative father of an unborn child when calculating the eligibility of a pregnant woman is prohibited.

The Presumptive Eligibility Policy, DMA-5032, Presumptive Eligibility Determination Form for Pregnancy – Related Care, and DMA-5033, Presumptive Eligibility Transmittal form, are revised to incorporate this change. Follow these revised instructions for all presumptive eligibility applications in process or taken on or after receipt of this administrative letter.

Note also that the DMA-5032, Presumptive Eligibility Determination Form was previously revised to indicate that non-applicants are not required to furnish their Social Security numbers.

This letter obsoletes DMA Administrative Letter No. 02-04 and Administrative Letter No. 02-04, Addendum 5.

If you have any questions regarding this information, please contact your Medicaid Program Representative.  For any issues that are not able to be handled through that venue, Mrs. Angela Floyd, Assistant Director for Recipient and Provider Services, will be your point of contact and can be reached at (919) 855-4000.

William W. Lawrence, Jr., M.D.

Acting Director

(This material was researched and written by William Appel, Policy Consultant, Medicaid Eligibility Unit)

Provider Instructions for Determining

Presumptive Eligibility

I. GENERAL

To encourage greater use of prenatal care by poor pregnant women, qualified Medicaid providers may determine a pregnant woman to be presumptively eligible for Medicaid while the county dss determines her ongoing eligibility for Medicaid. During the period of presumptive eligibility, the pregnant woman is eligible only for ambulatory prenatal care provided by any Medicaid enrolled provider. This includes prescriptions.

A. There are three criteria for establishing presumptive eligibility:

1. There must be medical verification of pregnancy.

2. The pregnant woman cannot be an inmate of a public institution.

3. The pregnant woman’s family income must be equal to or less than 185% of the federal poverty level. The amount of family income is based on the pregnant woman’s statement.

You are responsible for medically establishing that the woman is pregnant and for completing a presumptive eligibility determination as outlined in the instructions which follow.

B. Refer the pregnant woman to the department of social services (dss) in the county in which she resides to apply for Medicaid.

C. Encourage the woman to apply as soon as possible so as not to lose potential Medicaid benefits.

D. If she fails to apply by the last workday of the month following the month she is determined presumptively eligible, presumptive eligibility ends on the last calendar day of that month. In this situation, the provider will be guaranteed payment only for presumptive eligibility services.

E. If she applies by the last workday of the month following the month she is determined presumptively eligible, she remains presumptively eligible for Medicaid until the county makes an eligibility determination.

F. During the presumptive eligibility period, the pregnant woman is eligible only for ambulatory prenatal care provided by any Medicaid enrolled provider. Delivery or hospitalization is not covered unless the woman is subsequently determined Medicaid eligible for the days of inpatient care.

(I.)

G. If the pregnant woman applies for Medicaid for Pregnant Women (MPW) and is determined eligible by the county dss, she is covered for a full range of pregnancy-related services (including delivery), beginning with the first month she meets all eligibility requirements through 60 days following termination of pregnancy. However, services are limited to those that are related to her pregnancy. To identify this coverage group, a pink Medicaid ID Card will be issued.

H. The pregnant woman may also apply for other Medicaid programs or Work First Family Assistance. If determined eligible, she is covered for all Medicaid covered services beginning with the first day she meets all eligibility requirements. Eligibility must be redetermined every six or twelve months and changes in situations do affect eligibility. A blue Medicaid ID Card identifies those individuals eligible for full coverage.

I. The pregnant woman is limited to one period of presumptive eligibility per pregnancy.

II. provider instructions

A. Conduct an interview with the pregnant woman as instructed in III., Interview Guide.

B. Complete an income calculation based on the pregnant woman’s statement of income as instructed in IV., Income Eligibility. Use the Income Calculation Guide in V.

C. If the countable net monthly income is equal to or less than the 185% poverty level for her family size, she is presumptively eligible. Complete the presumptive eligibility determination form and a transmittal form.

1. Instructions for Completion of DMA-5032, Presumptive Eligibility Determination Form

a. Complete the DMA-5032 according to instructions on the back of the form. The form must include the provider’s signature and ID number, the pregnant woman’s signature, the date signed and medical verification of pregnancy. If any of this information is missing, the county dss will return the form to you for completion.

b. If the pregnant woman is determined presumptively eligible, route the original copy of DMA-5032 to the county dss within 5 workdays. Give one copy of the DMA-5032 to the pregnant woman and retain the other copy for your record.

c. If the pregnant woman is found to be ineligible, document this on the form and file in your records with a copy of the denial form. Do not send any copies to the dss. Do not give a copy to the pregnant woman.

2. Instructions for Completion of DMA-5033, Presumptive Eligibility Transmittal Form

a. If the pregnant woman is determined presumptively eligible, complete one original and 3 copies of this form.

(II.C.2.)

b. If you know the pregnant woman is enrolled in NC Health Choice, note this on the DMA-5033. She cannot be authorized for presumptive eligibility until NC Health Choice is terminated.

c. Complete the top half of the form with the pregnant woman’s name, provider name and ID number, and the date the form is completed.

e. Identify the county department of social services by entering the name of the county in which the pregnant woman resides.

f. Enter the date that the pregnant woman must apply at the county dss. This is the last working day of the month following the month presumptive eligibility is determined.

g. Give one copy of the form to the pregnant woman.

h. Send the original and one copy to the county dss with the Presumptive Eligibility Determination Form. The dss will complete the bottom half and return it to you.

(1) If the pregnant woman does not apply at the county dss by the last workday of the month following the month she was determined presumptively eligible, the returned form will indicate the Medicaid ID number and the dates of presumptive eligibility for billing purposes.

(2) If the pregnant woman does apply, dss will indicate the date of the application. Presumptive eligibility will be authorized the first of each month until a determination is made on the Medicaid application.

3. Instructions for Completion of DMA-5035, Presumptive Eligibility Denial

If the pregnant woman is not presumptively eligible, complete 2 copies of the DMA-5035. Give the original to the patient and keep the other copy for your file.

III. Interview Guide

A. During your interview, explain the Medicaid program to the pregnant woman.

1. The pregnant woman may be eligible to receive Medicaid for pregnancy-related services if countable income is equal to or less than 185% of the federal poverty levels listed in V., Income Calculation Guide.

2. If she is determined eligible she will receive Medicaid for all pregnancy-related services during her pregnancy and for 60 days after she delivers. Because of the limited scope of services, a pink Medicaid card will be issued. She may also be eligible for full coverage of all Medicaid covered services if she can meet more stringent eligibility requirements for other programs.

(III.A.)

3. Advise the pregnant woman that it is her responsibility to notify the provider when she receives her Medicaid card.

4. In addition to income, the following requirements must be met to receive Medicaid beyond the presumptive eligibility period.

a. Citizenship and Identity – She must meet citizenship and identification requirements.

b. State residence – She must live in N.C. with the intention to remain permanently or indefinitely or must be here employed or show that she entered N.C. with the intent to seek employment or with a job offer.

c. Enumeration – When she goes to the county department of Social Services, she must present a valid Social Security number or make an application for a Social Security number.

5. The presumptive eligibility period:

a. Begins on the date the pregnant woman signs the presumptive eligibility application and is determined by the provider to be presumptively eligible; and,

b. Ends on the earliest of the following dates:

(1). On the day the county dss makes an eligibility determination if the woman applies for Medicaid under any program, or

(2). On the last day of the month following the month the pregnant woman is determined presumptively eligible by the provider if she does not apply for Medicaid.

B. Conducting the interview

1. Ask the pregnant woman in which county she lives. Many times a mailing address does not necessarily indicate the county of residence.

2. When interviewing the applicant about family gross income, it is important to obtain accurate and complete information. Ask open-ended questions, such as:

a. Where do you work?

b. Where does your spouse work?

c. How do you get the money to pay your bills?

d. Who helps you pay your bills?

(III.B.2.)

e. Do you or your spouse receive Social Security or other government payments?

f. Do you or your spouse receive worker’s compensation or unemployment insurance?

g. Does anyone outside the home contribute money to you on a regular basis?

Accept the pregnant woman’s statement as to the gross income of herself and, if applicable, her spouse. If she cannot give a statement of income, ask that she find out and let you know. She may make a statement about income by telephone.

IV. Income eligibility

A. To be approved for presumptive eligibility, the pregnant woman’s countable family income must be equal to or less than 185% of the federal poverty level for the number in her family unit.

B. The family unit consists of the:

1. Pregnant woman, and

2. Unborn(s), and

3. Husband of the pregnant woman provided that:

a. He is living in the home or temporarily absent, and

b. Not receiving Work First, Supplemental Security Income (SSI) or Community Alternative Program (CAP).

4. Children of the pregnant woman and/or her spouse who are:

a. Under 21, and

b. Living in the home or temporarily absent, and

c. Not receiving Work First, SSI, special needs adoption assistance (IAS), foster care assistance (HSF), or CAP, and

d. Have never been married, and

e. Have never served in the military, and

f. Have not been legally emancipated.

Accept the pregnant woman’s statement as to her family composition.

C. Count the income of the following family unit members:

1. The pregnant woman and

(IV.C.)

2. The father of the unborn provided that:

a. He is married to the pregnant woman, and

b. Living in the home or temporarily absent, and

c. Not receiving Work First, SSI or CAP.

D. Determine the countable gross monthly income.

Gross income is comprised of both earned and unearned income.

1. Earned income is money received as wages or salary.

2. Unearned income is money received from Social Security, pensions, VA, dividends, alimony or support payments, contributions, etc.

The DMA-5034, Presumptive Eligibility Income Checklist, provides a listing of the most common types of countable income.

V. income calculation guide

A. Record on the DMA-5032 the applicant’s statement of gross income for the family unit.

1. Record frequency of receipt in designated column. Frequency will be weekly, bi-weekly, semi-monthly, monthly or annually. Contact the Medicaid Eligibility Unit at 919-855-4000 for further instructions if income is received at intervals other than those listed.

2. For fluctuating income, record the most recent amount received.

3. If income has terminated, do not count.

4. Do not count new income that is anticipated but not yet received.

5. Child support payments are treated as income to the child.

a. If the pregnant woman is a minor and receives child support from an absent parent:

(1) Count the full amount as income to the pregnant woman if she is the only recipient of the child support;

(2) Count her pro rata share of the total child support if any of her siblings are included in the child support payment.

(V.A.5.)

b. If the pregnant woman is not a minor and receives child support for her child:

(1) Do not count child support unless the payment includes spousal support.

(2) If it includes spousal support, treat the pregnant woman’s pro rata share as income.

6. Treat military allotments as income to the person whose name is on the allotment check.

7. If the pregnant woman is unsure about the amount of gross income, you may have her call you back. Be sure, however, she signs the DMA-5032 before leaving your office.

8. If she has not provided the necessary information within 3 workdays, deny her application for presumptive eligibility. Mail her the DMA-5035, Presumptive Eligibility Denial notice.

B. Calculate gross monthly income for the pregnant woman and her husband, if applicable.

1. Use the following formulas to convert earned income to a monthly amount:

• If received weekly, multiply weekly amount by 4.3.

• If received bi-weekly, multiply bi-weekly amount by 2.15.

• If received semi-monthly, multiply semi-monthly amount by 2.

• If received monthly, use monthly gross amount.

• If received annually, divide by 12.

2. Round each individual’s monthly income to the nearest dollar. If actual income is $.49 or less, round down. If actual income is $.50 or more, round up to next dollar amount.

3. Compute total gross income for the family unit.

4. Compare total gross family income to 185% of the federal poverty level for the number of family unit members listed in IV.B. Use the income chart in V.D.

5. If the total gross family income is equal to or less than 185% of the poverty income level for the number of people in the family unit, the pregnant woman is income eligible for presumptive eligibility.

6. If the total gross family income is greater than 185% of the poverty income level, follow the steps in C. to calculate net countable monthly income.

C. Calculate net countable monthly income for each person as follows:

1. For persons who have earned income:

a. Deduct any Earned Income Tax Credit (EITC).

b. Subtract $90 from gross earnings for each employed family unit member.

(V.C.1.)

b. Deduct child/incapacitated adult care costs up to $175 a month ($200 a month for children under two) for each individual in the household for whom care is being paid when:

(1) The cost of care is being paid by the pregnant woman or her spouse, and

(2) The charges are paid to someone outside the household.

e. The remaining amount is the countable monthly earned income.

d. Exclude income paid by either the pregnant woman or her husband, if living in the home or temporarily absent, for court ordered child support and/or spousal support to individuals not living in the home.

2. If the pregnant woman receives spousal support or if she is a minor and receives child support, subtract $50.00 from the gross monthly amount of child/spousal support.

3. Total the amount of countable earned income and countable unearned income.

5. The resulting amount is the total countable net income for the family unit.

6. Compare net countable income to 185% of poverty income level for the number of persons in the family unit. Use the income chart in V.D.

a. If the total countable income is equal to or less than 185% of the poverty income level, the pregnant woman is income eligible for presumptive eligibility.

b. If the total countable income is greater than the poverty income level, the pregnant woman is ineligible.

D. Monthly Poverty Income Level Effective 4/1/08

NUMBER IN FAMILY	185% of the Federal Poverty Level
2	$2,159
3	$2,714
4	$3,269
5	$3,824
6	$4,379
7	$4,934
8	$5,489

For each additional family unit member, add $555.