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5.2.4 Presumptive Eligibility for Pregnant Women

5.2.4.1 At the IM Agency

5.2.4.2 Assets and Income

 

Presumptive Eligibility ( PE ) for pregnant women provides pregnant U.S. citizens with ambulatory prenatal care under MA, beginning on the day that a qualified provider:

 

  1. Medically verifies the pregnancy.
     

  2. Determines that the woman's family income Income is anything you receive in cash or in kind that you can use to meet your needs for food, clothing, and shelter. does not exceed the PE for pregnant women income limit.

 

The provider should refer non-citizens to the Income Maintenace agency for a MA eligibility determination.

 

Qualified providers are certified under a contract with the Division of Health Care Financing ( DHCF ).  A qualified provider will determine if a pregnant woman is presumptively eligible for MA.

 

If she is, the qualified provider will:

 

  1. Assist the woman in completing and signing the Medicaid Presumptive Eligibility Application for Pregnant Women  ( HCF 10081 ).
     

  2. Fill out the temporary MA ID card at the bottom of the application form.  The certification dates will be from the date PE for pregnant women is determined through the end of the month following the month the determination is made.
     

  3. Give the woman a temporary MA ID card.
     

  4. Explain that the duration of her PE for pregnant women period depends on when she applies for MA at her income maintenance agency.
     

    1. If she applies for MA by the end of the month following the month in which she became eligible for PE for pregnant women, the PE for pregnant women period ends the day on which the agency completes processing her application.
       

    2. If she does not apply by the end of the month following the month in which she became eligible for PE for pregnant women, the PE for pregnant women period ends the last day of the month following the month in which she was determined eligible for PE for pregnant women.  If she is found ineligible for MA, her PE for pregnant women will end following adverse action notice.
       

  6. Send a copy of the completed application form to EDS and the income maintenance agency within five days.
     

5.2.4.1 At the IM Agency

If the woman applies for MA at the income maintenance agency on or before the last day of her PE for pregnant women period:

 

  1. Verify she is presumptively eligible by checking her temporary MA ID card.
     

Assist her in filing the application.  Consider the application filed if her name, address and signature are on the application.
 

  1. If you are unable to finish processing her application by the end of her PE for pregnant women period, extend her PE for pregnant women period for an additional calendar month.  Do the following:
     

    1. After the "PE Extension" on the temporary MA card, write a date that is 30 days after the "Thru" date.
       

    2. Stamp or write your agency's ID number and name on the temporary MA ID card.  Return the card to the woman.
       

Complete a Medicaid/BadgerCare Certification form  ( HCF 10110, former DES 3070 ) and send to EDS.  The medical status code is "PE" for categorically needy, "P2" for medically needy.  Enter the extended date for the PE for pregnant women.

 

If she is found ineligible for MA, complete a negative notice ( HCF 16001 ) to end the PE for pregnant women segment.  Check box three and complete the sentence to read:  "Your presumptive eligibility for pregnant women benefits will be stopped effective (write in date)".  Under "Explanation of Action," write the reason MA is being denied.  Mail one copy to the woman and one to the qualified provider.  Complete a Medicaid/BadgerCare Certification form  HCF 10110 ( formerly DES 3070 ), indicating the PE for pregnant women end date, and send to EDS.

 

If the woman does not apply for MA, or applies after the end of the month following the month in which she was determined eligible for PE for pregnant women, her PE for pregnant women ends with no extension.  Sending a negative notice is not necessary.  If she applies after the end of the month following the month she was determined eligible, process the application as you would a standard MA application.

 

5.2.4.2 Assets and Income

PE for pregnant women has no asset limit.  The categorically needy limit is 133% of the FPL and medically needy income limit is 185% of the FPL.  See 8.1.6.

 

This page last updated in Release Number: 03-02

Release Date: 04/01/03

Effective Date: 04/01/03