Family Healthcare (FAMIS) Manual – Table of Contents

0950.005.00 LEGAL BASIS AND OVERVIEW

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.