Presumptive Eligibility (PE) Programs Manual

IM-150 December 29, 2022; IM-21 March 3, 2022; IM-122 September 11, 2017; IM-51 May 18, 2017

An organization must complete and submit a Memorandum of Agreement (MOA) to begin the process of becoming a Presumptive Eligibility (PE) QE.

Remember the following when selecting categories on the MOA:

• All adults (age 19 and older) must be screened for every adult PE program, in the following order:
  • PE for Pregnant Women
  • PE for Parents/Caretaker Relatives
  • PE for Former Foster Care Youth
  • PE for Adult Expansion Group
• If the individual is not pregnant or eligible for PE for Pregnant Women (either TEMP or SMHB-PE), screen for PE for Parents/Caretaker Relatives (MHF-PE).
• If the individual is not eligible for MHF-PE, screen for PE for Former Foster Care Youth (FFCY-PE).
• If the individual is not eligible for FFCY-PE, screen for PE for Adult Expansion Program (AEG-PE).
• If the individual is not eligible for any category of PE, including AEG-PE, then they are not eligible for PE.

After the MOA is approved, designated employees (not contracted staff) of the QE must:

• Successfully complete all training required by the Family Support Division (FSD)
• Provide the FSD with a list of all trained staff.  This list must be kept current at all times by sending notification of staff changes to COLE.MHNPOLICY@dss.mo.gov
• Offer interested individuals/families the opportunity to complete the Application for Presumptive Eligibility (PE-1SSL) to receive benefits based on a PE determination

NOTE: To receive PE, a PE-1SSL must be completed, signed, and dated.

• Encourage and assist the individual/parent/caretaker to complete a regular MO HealthNet (MHN) application and submit it using the contact information provided at mydss.mo.gov/healthcare/apply.

NOTE: Completion of the IM-1SSL is in addition to completing the PE-1SSL.

Do not delay the PE determination for completion of the IM-1SSL, telephone application, or online application. Explain that they will be notified in writing when FSD makes a determination on their regular MHN application.

• Advise the individual/parent/caretaker that the end date for the presumptive period is the earlier of:

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

EXCEPTION:  The Temporary MO HealthNet During Pregnancy (TEMP) program is an exception when determining end dates.  If determined ineligible for regular MHN 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 apply to SMHB-PE.

NOTE: Inform the applicant that if a regular application (online, phone, or paper IM-1SSL) is not completed and submitted to FSD before the end of the PE period, PE coverage will end on the last day of the month following the month they are approved.

• Complete the PE determination using the QE PE Determination Worksheet (PE-2 Worksheet).
• Provide a copy of the appropriate form to applicant/family:

• • Not eligible – Qualified Entity Presumptive Eligibility Determination Worksheet (PE-2 Worksheet)
  • Eligible
    • MO HealthNet Presumptive Eligibility Authorization (PE-3) for Children, Parent/Caretaker Relatives, Adult Expansion Group, or Former Foster Care Youth; or
    • MO HealthNet TEMP/SMHB-PE Authorization (PE-3PW) for all pregnant women.

• Date stamp the PE-1SSL, IM-1SSL if received, and all other supporting documentation on the date received.
• Scan the appropriate forms to the Provider Portal the same or next working day after PE determination is completed:

• • If not eligible, send a copy of the signed PE-2 Worksheet
  • If eligible, send the following documents:
    • Copy of signed PE-2 Worksheet; and
    • Copy of PE-3 or PE-3PW

NOTE: DO NOT send the PE-1SSL to FSD.  This is kept on file in your facility. Any additional documentation should be sent separately as “Supporting Documents” to the Provider Portal.

• Comply with all state, federal, and Missouri Department of Social Services rules and regulations, including the Health Insurance Portability and Accountability Act (HIPAA), when conducting PE determinations.
• Maintain written or electronic records of all documents used in PE determination along with any related supporting documentation for a period of five (5) years from the date of the determination, unless litigation or audit has been started prior to the sixth year, then the record must be maintained until the litigation, or audit is resolved. These records will be made available to the department upon request.
• Notify FSD within ten (10) days of any changes in the point of contact information.
• If individual is found eligible, applicable services will be provided by MHN Fee-For-Service providers while the presumptive period remains in effect.
• Any documentation received after initial submission should be sent by the same method with the same subject line as “Supporting Documentation” through the Provider Portal.

QEs must verify on eMOMED if:

• Applicant is currently receiving full MHN coverage, or
• Applicant has received PE within the last 12 months or, if pregnant, during the current pregnancy

If the applicant meets either of the above criteria, the applicant is not eligible.

In addition, QEs will need a Departmental Client Number (DCN) for each applicant.

QEs may send an email to FSD.MEDESIVR@dss.mo.gov requesting the needed information.