Family Healthcare (FAMIS)

0945.010.00 QUALIFIED PROVIDER

  1. Definition

    A Qualified Provider is a Medicaid enrolled provider determined by the Family Support Division to meet qualifications necessary to make TEMP eligibility determinations.  Qualified providers are required by law to be providers who receive funds from specific federal programs.  Generally, qualified providers are limited to County Health Departments and health clinics that participate in required federal programs.  A listing of the Qualified Providers currently enrolled is located in Appendix A of this section.

  2. Qualified Provider Responsibilities

    Qualified Provider responsibilities are detailed in the Qualified Provider Manual, which is issued to each Qualified Provider.  Each county office has one Qualified Provider Manual.

    The qualified provider is responsible for screening all pregnant women who come to the provider for services to see if they are interested in healthcare coverage.

    If the pregnant woman wants healthcare coverage, the qualified provider will:

    1. Have the pregnant woman complete the appropriate portion of the QP-1 “Temporary Medicaid during Pregnancy (TEMP) Eligibility Determination”, providing information on income and household size.
    2. Based on the woman’s statement, make an eligibility determination for temporary Medicaid coverage.
    3. If the woman is eligible for TEMP:
      1. Provide her with a temporary Medicaid identification card (QP-2) covering the date of the determination through the last day of the month following date of determination.  Explain the use of and the limited coverage provided by the temporary Medicaid card.
      2. Tell the woman of her responsibility to make a formal application for MC+ with her local Family Support Division office by the end date on her temporary Medicaid identification card (QP-2).  Explain that if the woman files an application by this date, her temporary healthcare coverage could be extended to the date of final determination of her MC+ application.
      3. Send notice of the TEMP eligibility determination to the FSD office in the county where the woman resides the same or next day so that FSD receives it within 5 working days of the determination.
    4. If the woman is not eligible for TEMP:
      1. Provide her with a copy of the determination (QP-1) including the reason she is not eligible for temporary Medicaid.
      2. Advise the pregnant woman of her right to apply for MC+ with her FSD office for a formal determination of MC+ eligibility.
      3. Send notice that the woman is not eligible for TEMP to the woman’s county FSD office the same or next day so it is received by FSD within 5 working days of the determination.
  3. The Qualified Provider is also responsible to:
    1. Designate a member of the provider’s staff to be a liaison with the FSD office.
    2. Maintain adequate records on all TEMP eligibility determinations.