Presumptive Eligibility (PE) Programs Manual – Table of Contents

1900.010.00 LEGAL BASIS AND OVERVIEW

IM#51, May 18, 2017

Federal Law (Section 1920 of the Social Security Act) gives states the authority to provide medical assistance with respect to healthcare items and services during a presumptive eligibility period.  Section 435.1103 from the Patient Protection and Affordable Care Act of 2010 authorizes Qualified Entities (QE) to determine Presumptive Eligibility (PE) for the following programs:

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:  Temporary MO HealthNet During Pregnancy (TEMP) is 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 Show-Me Healthy Babies Presumptive Eligibility program)