Presumptive Eligibility (PE) Programs Manual

1900.010.00 Legal Basis and Overview

IM-21 March 3, 2022; IM-51 May 18, 2017

Federal Law (Section 1920 of the Social Security Act) and RSMo 208.151(12) gives states the authority to provide medical assistance with respect to healthcare items and services during a presumptive eligibility (PE) period for pregnant women (TEMP) (1990).

Federal Law (Section 1920A of the Social Security Act) gives states the authority to provide medical assistance with respect to healthcare items and services during a PE period for children (PC) (1997).

Section 1920B [42 U.S.C.1396r-1b] allows states, effective August 28, 2001, to provide a period of PE for Breast and Cervical Cancer Treatment (BCCT-PE)

Section 42 CFR 435.1103 authorizes Qualified Entities (QE) to determine PE for the following programs:

Section 2112(c) of the Social Security Act and Senate Bill 716 (2014) added section 208.662 to the Revised Statutes of Missouri (RSMo) which authorizes QEs to determine PE for Show-Me Healthy Babies (SMHB-PE)

Article IV Section 36(c) of the Missouri Constitution gives Missouri the authority to provide medical assistance for the Adult Expansion Group during a PE period (AEG-PE) (2020).

The Departmental Client Number (DCN) assigned to the PE applicant will serve as the MO HealthNet number for all PE programs.

NOTE: While Show-Me Healthy Babies is coverage for the unborn child, the mother’s DCN will be used for the PE application. The unborn child will be assigned a DCN at birth.

PE coverage is fee for service only. It cannot begin prior to the date the eligibility determination is made and ends the earlier of:

  • The date regular MO HealthNet is approved or denied (if an application is filed by the last day of the month following the month in which the determination for PE is made); or
  • The last day of the month following the month in which the determination of presumptive eligibility is made (if no application for MO HealthNet is filed by that date).

    EXCEPTION: TEMP has an exception to the end date.  If determined ineligible for regular MO HealthNet coverage, TEMP coverage will continue until the last day of the month following the month in which the determination for PE was made.  (This exception does not include the SMHB-PE program)