Presumptive Eligibility

 

What is Presumptive Eligibility?

Presumptive Eligibility allows specially trained health care providers, known as Qualified Entities (QE), to make Presumptive Eligibility determinations. This makes it possible for eligible individuals to gain immediate access to medical services for a temporary period of time, during which they should submit an application to be processed for on-going Medicaid coverage. 

How does Presumptive Eligibility help?

PE allows eligible individuals can get needed coverage while their application is being processed. This ensures that the individual will have access to needed services and medications, and that providers will be reimbursed for eligible services. 

How long does Presumptive Eligibility last?

Coverage begins on the date the QE makes the determination; there is no retroactive coverage.

The Presumptive Eligibility coverage for AEG, parents, children, Show-Me Healthy Babies, and former foster care youth ends the on the date regular MO HealthNet is approved or denied, provided an application is filed by the last day of the month following the month in which the determination for Presumptive Eligibility is made. If no application is made, coverage will end after the last day of the month following the month in which the determination was made. 

For pregnant women (TEMP) PE coverage will continue until the end of the month following the PE determination even if they are found ineligible for Medicaid during the regular application process.

Qualified Entities are also required to assist PE applicants in preparing and submitting applications for ongoing MO HealthNet coverage. Do not hold up submitting the PE application while the regular application is being completed. 

Community Mental Health Centers (CMHCs) and CSTAR providers may now become a qualified entity (QE) to determine and authorize presumptive eligibility (PE) for MO HealthNet (Medicaid) in the following categories: 

  • Presumptive Eligibility for Children (PC),
  • Temporary MO HealthNet During Pregnancy (TEMP), 
  • Show-Me Healthy Babies Presumptive Eligibility (SMHB-PE), 
  • Presumptive Eligibility for Parents/Caretaker Relatives (MHF-PE), 
  • Former Foster Care Youth Presumptive Eligibility (FFY-PE), or 
  • Presumptive Eligibility for Adult Expansion Group (AEG-PE). 

Note: CCBHOs are included as they are also CMHCs/CSTAR providers

 

Enrolling as a PE Qualified Entity: Overview 

To become a Qualified Entity, the provider must complete and sign a Memorandum of Agreement  (MOA M00769) for each location where staff will determine PE. The appropriate Checklists for the types of PE you wish to determine must also be completed. The necessary documents are available on the DSS Website to download, and can be found at: https://dss.mo.gov/bids/.  

Once the documents are completed and signed, the MOA M00769 and required Checklist(s) should be sent via email to Cole.MHNpolicy@dss.mo.gov

Once DSS approves your PE MOA, you will receive the executed MOA M00769 and your staff will get an email about training.

Note: The MOA M00455  is used for local public health associations (LPHAs) and Headstart, and the MOA M00748 is used for Qualified Hospitals.  These are NOT for use by CMHCs and CSTAR facilities.

Enrolling as a PE Qualified Entity: Completing the Checklists

Complete the checklists as follows: 

  • Children – check the last box : “Any other entity the State so deems, as approved by the Secretary; and is determined by the State agency to be capable of making determinations of the type described in paragraph (2)
  • MHF/FFY/AEG (adults) - check all squares, and the appropriate circles indicating you are a CMHC and/or CSTAR provider.
  • Pregnant women – Check A, B, and C.  Also check D if appropriate.  Although the checklist indicates you have to check A, B, C, and D, organizations that are Qualified Entities do PE for children or the adult groups are also qualified entities for pregnant women.
Enrolling as a PE Qualified Entity: Mandatory Staff Training

The names of the staff who will determine PE must be sent to to Deborah.Fletcher@dss.mo.gov.  

All staff must go through training before they can make PE determinations.

For training, DSS Family Support Division (FSD) will need a list of:
•    all staff you would like trained;
•    an email address for each person; and
•    at which site they work (if you have multiple sites). 

Once DSS approves your PE MOA, you will receive the executed MOA M00769 and your staff will get an email about training.

Enrolling as a PE Qualified Entity: Selecting MO HealthNet categories

When selecting MO Health categories for which you want to make PE determinations, please keep in mind the following:

  • All adults (age 19 and older) must be screened for every adult PE program, in this order:
    • PE for Pregnant Women
    • PE for Parent/Caretaker Relative
    • PE for Former Foster Care Youth
    • PE for Adult Expansion Group
  • Before making determinations for AEG-PE, the staff must first check eligibility for the other three (3) adult PE programs in the correct order.

Once the provider has successfully enrolled and is a PE Qualified Entity they can begin to process Presumptive Eligibility applications. 

PE Application Process 

A special application form (PE-1SSL) is used for PE. 

  • the QE completes a worksheet (PE-2) to determine PE eligibility based on the client’s statement on the application of the household composition, income, pregnancy, age, and Medicare eligibility (AEG only) 
  • if eligible, the QE gives the client an approval form (PE-3 or PE-3PW) with their Medicaid number (DCN) and coverage begin date (date of determination) 
  • the QE scans the worksheet and approval form to the FSD PE Provider Portal the day of or the next working day after the determination
  • FSD enters the PE eligibility in the system on the day of receipt or the next working day.  The eligibility will be in eMOMed and CIMOR the day after entered by FSD.  

A regular Medicaid application should also be completed at the same time as the PE application and submitted to FSD. See our informational page Applying for MO HealthNet (Medicaid) for information on how to complete and submit a regular application. 

Presumptive Eligibility ME codes and Benefit Packages 
  • Presumptive Eligibility for Children (PC)
    • ME 87
  • Temporary MO HealthNet During Pregnancy (TEMP)
    • ME 58 & 59
  • Show-Me Healthy Babies Presumptive Eligibility (SMHB-PE)
    • ME 94 
  • Presumptive Eligibility for Parents/Caretaker Relatives (MHF-PE)
    • ME 05, same as regular parent/caretakers 
  • Former Foster Care Youth Presumptive Eligibility (FFY-PE)  
    • ME 38, same as regular former foster care youth
  • Presumptive Eligibility for Adult Expansion Group (AEG-PE)
    • ME E2, same as regular AEG

Persons on PE for AEG, parents/caretakers, children, and former foster care youth receive the same benefit package as persons approved for regular Medicaid in those categories (including CPR/CSTAR) and can receive covered services from any MO HealthNet provider.  

PE for pregnant women (ME 58, 59) and Show-ME Healthy Babies (ME 94) covers only ambulatory prenatal care, which does not include CPR or CSTAR services.